Vomiting and Nausea

Vomiting and Nausea Overview

Vomiting and nausea are not illnesses but common complaints that go along with many diseases and conditions. The problems with nausea and vomiting are related to the cause. Nausea and vomiting from motion sickness or seasickness or cancer therapy can result in loss of water and electrolytes, which can lead to dehydration. Vomiting and nausea known as morning sickness may occur during pregnancy.

• Nausea, the unmistakable, unpleasant, queasy feeling in your throat or stomach that may result in vomiting, is a message sent by your brain. It tells you that something isn’t right.

• Vomiting means emptying your stomach by a strong gag and retch that leads to throwing up. The stomach’s contents are forcefully expelled through the mouth. Vomiting can come in waves as the natural movement (known as peristalses) is reversed, and involuntary contractions in the walls of your stomach and esophagus force the stomach contents out. Sometimes coughing or spitting up mucus from the lungs is confused with vomiting. You can only vomit from the stomach.

• Retching is the movement of the stomach and esophagus without vomiting. Sometimes this is called the dry heaves. Most people experiencing the dry heaves would rather just throw up and “get it over with.”

Vomiting and Nausea Causes

Nausea and vomiting are controlled by the same parts of the brain that control involuntary bodily functions. Vomiting is actually a reflex triggered by a signal from the brain.

• The signal to vomit can be stimulated by smells, taste, various illnesses and emotions (such as fear), pain, injury, infection, food irritation, dizziness, motion, and other changes in the body, specifically these:
  • Eating disorders (anorexia and bulimia)
  • Food poisoning
  • Certain viruses
  • Motion sickness (car sickness, seasickness)
  • Vertigo (the sensation that the room is spinning around)
  • Head injuries (such as a concussion or bleeding injury)
  • Gallbladder disease or appendicitis
  • Migraine (a severe form of headache)
  • Brain tumors
  • Brain infections (such as meningitis)
  • Hydrocephalus (too much fluid in the brain)
• When you take certain medications, nausea and vomiting can be a common side effect. Usually nausea is not an allergy, which is a severe reaction that can include a rash or trouble breathing, but an unwanted part of the medicine. Some medicines such as those used in cancer treatment (chemotherapy) and strong pain killers are well known for causing nausea and vomiting
• Many people experience nausea and vomiting as a side effect of the anesthesia from surgery.
• Stomach problems such as blockage (pyloric obstruction, a condition that causes forceful spitting up in infants) cause nausea and vomiting.
• Bleeding into the stomach from different causes can also cause vomiting. Sometimes the swallowed blood from a nosebleed can cause nausea and vomiting.
• Infection or irritation of the intestines can cause nausea and vomiting.
• Low or high body chemicals and minerals can cause nausea and vomiting, as well as toxins in the body.
• Alcohol from beer, wine, and liquor is turned into a chemical, which causes nausea and vomiting. This is felt the next morning as a “hangover.”
• Early pregnancy is a common cause of nausea and vomiting. Morning sickness usually happens in the first few months but sometimes can last throughout the pregnancy.

nausea

Vomiting and Nausea Symptoms

• Nausea is a sensation that almost everyone knows from personal experience. It is a feeling of unease that frequently includes an upset stomach, dizziness, and anxiety. There is often an urge to vomit. You often feel as if this sensation comes from your stomach, but it is mostly controlled by the brain.

• Vomiting, however, frequently improves the sensation of nausea, at least temporarily. Vomiting occurs when the stomach forcefully sends its contents up to and out the mouth. If the nausea is severe, vomiting can continue after all the food and liquid has been sent out. This is called the dry heaves.

• When vomiting leads to dehydration from loss of fluids, you may have increased thirst and dry lips and dry mouth. You may not urinate often. In children, signs of dehydration include dry lips and mouth, sunken eyes, rapid breathing, and dry diapers, indicating the child is not producing urine.

When to Seek Medical Care

Call your health care provider when the nausea is so severe that you are unable to take care of yourself. Call also if the vomiting is so bad that you can’t keep any liquids down at all for more than 8-10 hours.

• Vomiting blood is a warning sign and a reason to see your health care provider. Blood may be bright red or dark red. Sometimes old blood can look brown like coffee grounds.
• If you are taking care of a child, call for medical advice if the child does not urinate in 6-8 hours (or has dry diapers for that period of time). Signs and symptoms of dehydration in children and dehydration in adults (severe loss of body fluids) include weakness, dizziness, lightheadedness—these symptoms are worse when standing—dry mouth and lips, less urine than normal, dark-yellow and smelly urine, and severe thirst.

Seek medical attention at a hospital’s emergency department in these circumstances:

• If you are experiencing nausea or vomiting and severe belly pain
• Vomiting with fever, especially in a child
• If you can see blood in the vomit
• If vomiting won’t stop and you are unable to keep down any fluids
• If you have a known head injury
• If there are other medical conditions present such as heart disease or diabetes
• If you observe any signs of confusion or extreme weakness
• If a new or severe headache is also present

Exams and Tests

Your health care provider will take a thorough medical history and conduct a physical exam to find out the cause of your discomfort and to look for other problems.

Certain tests may be performed:

• Blood tests (to check body minerals and chemicals and blood cell numbers)
• Urine (to check for evidence of dehydration and infection)
• Brain scan (a CT scan to look for signs of head injury or bleeding)

Vomiting and Nausea Treatment

Most of the time, nausea and vomiting go away on their own as quickly as they started and can be managed at home.

Treatment for nausea and vomiting usually involves medicine to decrease the nausea and fluid replacement for dehydration.

Self-Care at Home

The mainstay of home treatment is to drink fluids. Fluid intake helps correct electrolyte imbalance, which may stop vomiting. This means drinking fluids, which may be the farthest thing from your mind. But it is vital to prevent yourself from becoming dehydrated from fluid loss.

• Start with small amounts, such as 4-8 ounces at a time for adults and 1 ounce or less at a time for children. Only use clear liquids (such as clear soup broth, juice, lemon-lime soda). If you’re not sure if it’s clear, put the liquid in a clear glass bowl and try to read something through it. If you can’t read, it’s not clear.
• Avoid milk and any dairy products. They can make your nausea and vomiting worse.
• Work your way up to soft foods, gelatin, oatmeal, yogurt, and similar soft foods and go back to liquids if the nausea and vomiting return.

Dehydration in children: Children should be given oral rehydration solutions such as Pedialyte, Rehydrate, Resol, and Rice-Lyte.

• Cola, tea, fruit juice, and sports drinks will not correctly replace fluid or electrolytes lost from vomiting. Nor will plain water. In addition, plain water will not replace electrolytes and may dilute electrolytes to the point of seizures.
• In underdeveloped nations or regions without available commercial pediatric drinks, the World Health Organization has established a field recipe for fluid rehydration: Mix 2 tablespoons of sugar (or honey) with ¼ teaspoon of table salt and ¼ teaspoon of baking soda. (Baking soda may be substituted with ¼ teaspoon of table salt.) Mix in 1 liter (1 qt) of clean or previously boiled water.

Dehydration in adults: Although adults and adolescents have a larger electrolyte reserve than children, electrolyte imbalance and dehydration may still occur as fluid is lost through vomiting. Severe symptoms and dehydration usually develop as complications of medication use or chronic diseases such as diabetes or kidney failure. But symptoms may occur in healthy people.

• Initially, adults should eat ice chips and clear, noncaffeinated, nondairy liquids such as Gatorade, ginger ale, fruit juices, and Kool-Aid or other commercial drink mixes.
• After 24 hours of fluid diet without vomiting, begin a soft-bland solid diet such as the BRAT diet: bananas, rice, applesauce without sugar, toast, pasta, and potatoes.

Medical Treatment

• Fluids are given by mouth if you can keep them down, or through a vein into the bloodstream. The IV route is a common way to give fluids back to the body in moderate to severe dehydration.
• Treatment will also be given for the specific cause, if found.

Fever

What Is Fever?

Fever occurs when the body’s internal “thermostat” raises the body temperature above its normal level. This thermostat is found in the part of the brain called the hypothalamus. The hypothalamus knows what temperature your body should be (usually around 98.6° Fahrenheit, or about 37° Celsius) and will send messages to your body to keep it that way.

Most people’s body temperatures even change a little bit during the course of the day: It’s usually a little lower in the morning and a little higher in the evening and can fluctuate as kids run around, play, and exercise.

Sometimes, though, the hypothalamus will “reset” the body to a higher temperature in response to an infection, illness, or some other cause. So, why does the hypothalamus tell the body to change to a new temperature? Researchers believe turning up the heat is the body’s way of fighting the germs that cause infections and making the body a less comfortable place for them.

What Causes Fever?

It’s important to remember that fever by itself is not an illness — it’s usually a symptom of an underlying problem. Fever has several potential causes:

Infection: Most fevers are caused by infection or other illness. Fever helps the body fight infections by stimulating natural defense mechanisms.

Overdressing: Infants, especially newborns, may get fevers if they’re overbundled or in a hot environment because they don’t regulate their body temperature as well as older children. However, because fevers in newborns can indicate a serious infection, even infants who are overdressed must be evaluated by a doctor if they have a fever.

Immunizations: Babies and children sometimes get a low-grade fever after getting vaccinated.

Although teething may cause a slight rise in body temperature, it’s probably not the cause if a child’s temperature is higher than 100° Fahrenheit (37.8° Celsius).

When Can a Fever Be a Sign of Something Serious?

In the past, doctors advised treating a fever on the basis of temperature alone. But now they recommend considering both the temperature and the child’s overall condition.

Kids whose temperatures are lower than 102° Fahrenheit (38.9° Celsius) often don’t require medication unless they’re uncomfortable. There’s one important exception to this rule: If you have an infant 3 months or younger with a rectal temperature of 100.4° Fahrenheit (38° Celsius) or higher, call your doctor or go to the emergency department immediately. Even a slight fever can be a sign of a potentially serious infection in very young infants.

If your child is between 3 months and 3 years old and has a fever of 102.2° Fahrenheit (39° Celsius) or higher, call the doctor to see if he or she needs to see your child. For older kids, take behavior and activity level into account. Watching how your child behaves will give you a pretty good idea whether a minor illness is the cause or if your child should be seen by a doctor.

The illness is probably not serious if your child:

• is still interested in playing
• is eating and drinking well
• is alert and smiling at you
• has a normal skin color
• looks well when his or her temperature comes down

And don’t worry too much about a child with a fever who doesn’t want to eat. This is very common with infections that cause fever. For kids who still drink and urinate normally, not eating as much as usual is OK.

How Do I Know if My Child Has a Fever?

A gentle kiss on the forehead or a hand placed lightly on your child’s skin is often enough to give you a hint that your child has a fever. However, this method of taking a temperature (called tactile temperature) is dependent on the person doing the feeling and doesn’t give an accurate measure of temperature.

Use a reliable thermometer to tell if your child has a fever when his or her temperature is at or above one of these levels:

• 100.4° Fahrenheit (38° Celsius) measured rectally (in the bottom)
• 99.5° Fahrenheit (37.5° Celsius) measured orally (in the mouth)
• 99° Fahrenheit (37.2° Celsius) measured in an axillary position (under the arm)

But how high a fever is doesn’t tell you much about how sick your child is. A simple cold or other viral infection can sometimes cause a rather high fever (in the 102°–104° Fahrenheit / 38.9°–40° Celsius range), but this doesn’t usually indicate a serious problem. And serious infections may cause no fever or even an abnormally low body temperature, especially in infants.

Because fevers may rise and fall, a child with fever might experience chills as the body tries to generate additional heat as its temperature begins to rise. The child may sweat as the body releases extra heat when the temperature starts to drop.

Sometimes kids with a fever breathe faster than usual and may have a higher heart rate. You should call the doctor if your child is having difficulty breathing, is breathing faster than normal, or continues to breathe fast after the fever comes down.

Different Types of Thermometers

Whichever type of thermometer you choose, be sure you know how to use it correctly to get an accurate reading. Keep and follow the manufacturer’s recommendations for any thermometer.

Digital thermometers usually provide the quickest, most accurate readings. They come in many sizes and shapes, are available at most supermarkets and pharmacies, and are available in a range of prices. Although you should read the manufacturer’s instructions to determine what method or methods the thermometer is designed for, many digital thermometers can be used for the following temperature-taking methods:

• oral (in the mouth)
• rectal (in the bottom)
• axillary (under the arm)

Digital thermometers usually have a plastic, flexible probe with a temperature sensor at the tip and an easy-to-read digital display on the opposite end.

Electronic ear thermometers measure the tympanic temperature — the temperature inside the ear canal. Although they’re quick and easy to use in older babies and children, electronic ear thermometers aren’t as accurate for infants 3 months or younger as digital thermometers and are more expensive.

Plastic strip thermometers (small plastic strips that you press against your child’s forehead) may be able to tell you whether your child has a fever, but they aren’t reliable for taking an exact measurement, especially in infants and very young children. If you need to know your child’s exact temperature, plastic strip thermometers are not the way to go.

Forehead thermometers also may be able to tell you if your child has a fever, but are not as accurate as oral or rectal digital thermometers.

Pacifier thermometers may seem convenient, but again, their readings are less reliable than rectal temperatures and shouldn’t be used in infants younger than 3 months. They also require the child to keep the pacifier in the mouth for several minutes without moving, which is a nearly impossible task for most babies and toddlers.

Glass mercury thermometers were once common, but the American Academy of Pediatrics (AAP) now says they should not be used because of concerns about possible exposure to mercury, which is an environmental toxin. (If you still have a mercury thermometer, do not simply throw it in the trash where the mercury can leak out. Talk to your doctor or your local health department about how and where to dispose of a mercury thermometer.)

Thermometer

How to Use a Digital Thermometer

A digital thermometer offers the quickest, most accurate way to take a child’s temperature and can be used in the mouth, armpit, or rectum. Before you use one, read the directions thoroughly. You need to know how the thermometer signals that the reading is complete (usually, it’s a beep or a series of beeps or the temperature flashes in the digital window on the front of the thermometer).

First, turn on the thermometer and make sure the screen is clear of any old readings. If your thermometer uses disposable plastic sleeves or covers, put one on according to the manufacturer’s instructions. Remember to discard the sleeve after each use and to clean the thermometer according to the manufacturer’s instructions before putting it back in its case.

To take a rectal temperature: Before becoming parents, most people cringe at the thought of taking a rectal temperature. But don’t worry — it’s a simple process:

1. Lubricate the tip of the thermometer with a lubricant, such as petroleum jelly.
2. Place your child:
   - belly-down across your lap or on a firm, flat surface and keep your palm along the lower back
   - or face-up with legs bent toward the chest with your hand against the back of the thighs
3. With your other hand, insert the lubricated thermometer into the anal opening about ½ inch to 1 inch (about 1.25 to 2.5 centimeters). Stop if you feel any resistance.
4. Steady the thermometer between your second and third fingers as you cup your hand against your baby’s bottom. Soothe your child and speak quietly as you hold the thermometer in place.
5. Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading.

To take an oral temperature: This process is easy in an older, cooperative child.

1. Wait 20 to 30 minutes after your child finishes eating or drinking to take an oral temperature, and make sure there’s no gum or candy in your child’s mouth.
2. Place the tip of the thermometer under the tongue and ask your child to close his or her lips around it. Remind your child not to bite down or talk, and to relax and breathe normally through the nose.
3. Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading.

To take an axillary temperature: This is a convenient way to take a child’s temperature. Although not as accurate as a rectal or oral temperature in a cooperative child, some parents may prefer to take an axillary temperature, especially for kids who can’t hold a thermometer in their mouths.

1. Remove your child’s shirt and undershirt, and place the thermometer under an armpit (it must be touching skin only, not clothing).
2. Fold your child’s arm across the chest to hold the thermometer in place.
3. Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading.

Whatever method you choose, keep these additional tips in mind:

• Never take a child’s temperature right after a bath or if he or she has been bundled tightly for a while — this can affect the temperature reading.
• Never leave a child unattended while taking a temperature.

Helping Kids Feel Better

Again, not all fevers need to be treated. And in most cases, a fever should be treated only if it’s causing a child discomfort. Here are ways to alleviate symptoms that often accompany a fever:

• If your child is fussy or appears uncomfortable, you can give acetaminophen or ibuprofen based on the package recommendations for age or weight. If you don’t know the recommended dose or your child is younger than 2 years, call the doctor to find out how much to give. Remember that fever medication will usually temporarily bring a temperature down, but it will not return it to normal — and it won’t treat the underlying reason for the fever. (Unless instructed by a doctor, never give aspirin to a child due to its association with Reye syndrome, a rare but potentially fatal disease.) Infants under 2 months old should not be given any medication for fever without being evaluated by a doctor. If your child has any medical problems, check with the doctor to see which medication is best to use.
• Giving a sponge bath can make your child more comfortable and help bring the fever down. Use only lukewarm water; cool water may cause shivering, which actually raises body temperature. Never use alcohol (it can cause poisoning when absorbed through the skin) or ice packs/cold baths (they can cause chills that may raise body temperature).
• Dress your child in lightweight clothing and cover him or her with a light sheet or blanket. Overdressing and overbundling can prevent body heat from escaping and can cause a temperature to rise.
• Make sure your child’s room is a comfortable temperature — not too hot or too cold.
• Offer plenty of fluids to avoid dehydration — a fever will cause a child to lose fluids more rapidly. Water, soup, ice pops, and flavored gelatin are all good choices. Avoid drinks containing caffeine, including colas and tea, because they can cause increased urination.
• If your child also is vomiting and/or has diarrhea, ask the doctor if you should give an electrolyte (rehydration) solution made especially for kids. You can find these solutions at pharmacies and supermarkets. Don’t offer sports drinks — they’re not designed for younger children, and the added sugars may make diarrhea worse. Also, limit your child’s intake of fruits and apple juice.
• In general, let your child eat what he or she wants (in reasonable amounts) but don’t force eating if your child doesn’t feel like it.
• Make sure your child gets plenty of rest. Staying in bed all day isn’t necessary, but a sick child should take it easy.
• It’s best to keep a child with a fever home from school or child care. Most doctors feel that it’s safe to return when the temperature has been normal for 24 hours.

Diarrhea

What is diarrhea?

Diarrhea is an increase in the frequency of bowel movements or a decrease in the form of stool (greater looseness of stool). Although changes in frequency of bowel movements and looseness of stools can vary independently of each other, changes often occur in both.

Diarrhea needs to be distinguished from four other conditions. Although these conditions may accompany diarrhea, they often have different causes and different treatments than diarrhea. These other conditions are:

1. incontinence of stool, which is the inability to control (delay) bowel movements until an appropriate time, for example, until one can get to the toilet

1. rectal urgency, which is a sudden urge to have a bowel movement that is so strong that if a toilet is not immediately available there will be incontinence

1. incomplete evacuation, which is a sensation that another bowel movement is necessary soon after a bowel movement, yet there is difficulty passing further stool the second time

1. bowel movements immediately after eating a meal

How is diarrhea defined?

Diarrhea can be defined in absolute or relative terms based on either the frequency of bowel movements or the consistency (looseness) of stools.

Frequency of bowel movements. Absolute diarrhea is having more bowel movements than normal. Thus, since among healthy individuals the maximum number of daily bowel movements is approximately three, diarrhea can be defined as any number of stools greater than three. Relative diarrhea is having more bowel movements than usual. Thus, if an individual who usually has one bowel movement each day begins to have two bowel movements each day, then diarrhea is present-even though there are not more than three bowel movements a day, that is, there is not absolute diarrhea.

Consistency of stools. Absolute diarrhea is more difficult to define on the basis of the consistency of stool because the consistency of stool can vary considerably in healthy individuals depending on their diets. Thus, individuals who eat large amounts of vegetables will have looser stools than individuals who eat few vegetables. Stools that are liquid or watery are always abnormal and considered diarrheal. Relative diarrhea is easier to define based on the consistency of stool. Thus, an individual who develops looser stools than usual has diarrhea–even though the stools may be within the range of normal with respect to consistency.

Why does diarrhea develop?

With diarrhea, stools usually are looser whether or not the frequency of bowel movements is increased. This looseness of stool–which can vary all the way from slightly soft to watery–is caused by increased water in the stool. During normal digestion, food is kept liquid by the secretion of large amounts of water by the stomach, upper small intestine, pancreas, and gallbladder. Food that is not digested reaches the lower small intestine and colon in liquid form. The lower small intestine and particularly the colon absorb the water, turning the undigested food into a more-or-less solid stool with form. Increased amounts of water in stool can occur if the stomach and/or small intestine secretes too much fluid, the distal small intestine and colon do not absorb enough water, or the undigested, liquid food passes too quickly through the small intestine and colon for enough water to be removed. Of course, more than one of these abnormal processes may occur at the same time.

For example, some viruses, bacteria and parasites cause increased secretion of fluid, either by invading and inflaming the lining of the small intestine (inflammation stimulates the lining to secrete fluid) or by producing toxins (chemicals) that also stimulate the lining to secrete fluid but without causing inflammation. Inflammation of the small intestine and/or colon from bacteria or from ileitis/colitis can increase the rapidity with which food passes through the intestines, reducing the time that is available for absorbing water. Conditions of the colon such as collagenous colitis can block the ability of the colon to absorb water.

Diarrhea generally is divided into two types, acute and chronic.

• Acute diarrhea lasts from a few days up to a week.
• Chronic diarrhea can be defined in several ways but almost always lasts more than three weeks.

It is important to distinguish between acute and chronic diarrhea because they usually have different causes, require different diagnostic tests, and require different treatment.

What are common causes of acute diarrhea?

The most common cause of acute diarrhea is infection–viral, bacterial, and parasitic. Bacteria also can cause acute food poisoning. A third important cause of acute diarrhea is starting a new medication.

Viral gastroenteritis

Viral gastroenteritis (viral infection of the stomach and the small intestine) is the most common cause of acute diarrhea worldwide. Symptoms of viral gastroenteritis (nausea, vomiting, abdominal cramps, and diarrhea) typically last only 48-72 hrs. Unlike bacterial enterocolitis (bacterial infection of the small intestine and colon), patients with viral gastroenteritis usually do not have blood or pus in their stools and have little if any fever.

Viral gastroenteritis can occur in a sporadic form (in a single individual) or in an epidemic form (among groups of individuals). Sporadic diarrhea probably is caused by several different viruses and is believed to be spread by person-to-person contact. The most common cause of epidemic diarrhea (for example, on cruise ships) is infection with a family of viruses known as caliciviruses of which the genus norovirus is the most common (for example, “Norwalk agent”). The caliciviruses are transmitted by food that is contaminated by sick food-handlers or by person-to-person contact.

Food poisoning

Food poisoning is a brief illness that is caused by toxins produced by bacteria. The toxins cause abdominal pain (cramps) and vomiting and also cause the small intestine to secrete large amounts of water that leads to diarrhea. The symptoms of food poisoning usually last less than 24 hours. With some bacteria, the toxins are produced in the food before it is eaten, while with other bacteria, the toxins are produced in the intestine after the food is eaten.

Symptoms usually appear within several hours when food poisoning is caused by toxins that are formed in the food before it is eaten. It takes longer for symptoms to develop when the toxins are formed in the intestine (because it takes time for the bacteria to produce the toxins). Therefore, in the latter case, symptoms usually appear after 7-15 hours.

Staphylococcus aureus is an example of a bacterium that produces toxins in food before it is eaten. Typically, food contaminated with Staphylococcus (such as salad, meat or sandwiches with mayonnaise) is left un-refrigerated at room temperature overnight. The Staphylococcal bacteria multiply in the food and produce toxins. Clostridium perfringens is an example of a bacterium that multiplies in food (usually canned food), and produces toxins in the small intestine after the contaminated food is eaten.

Traveler’s diarrhea

There are many strains of E. coli bacteria. Most of the E. coli bacteria are normal inhabitants of the small intestine and colon and are non-pathogenic, meaning they do not cause disease in the intestines. Nevertheless, these non-pathogenic E. coli can cause diseases if they spread outside of the intestines, for example, into the urinary tract (where they cause bladder or kidney infections) or into the blood stream (sepsis).

Certain strains of E. coli, however, are pathogenic (meaning they can cause disease in the small intestine and colon). These pathogenic strains of E. coli cause diarrhea either by producing toxins (called enterotoxigenic E. coli or ETEC) or by invading and inflaming the lining of the small intestine and the colon and causing enterocolitis (called enteropathogenic E. coli or EPEC). Traveler’s diarrhea usually is caused by an ETEC strain of E. coli that produces a diarrhea-inducing toxin.

Tourists visiting foreign countries with warm climates and poor sanitation (Mexico, parts of Africa, etc.) can acquire ETEC by eating contaminated foods such as fruits, vegetables, seafood, raw meat, water, and ice cubes. Toxins produced by ETEC cause the sudden onset of diarrhea, abdominal cramps, nausea, and sometimes vomiting. These symptoms usually occur 3-7 days after arrival in the foreign country and generally subside within 3 days. Occasionally, other bacteria or parasites can cause diarrhea in travelers (for example, Shigella, Giardia, Campylobacter). Diarrhea caused by these other organisms usually lasts longer than 3 days.

Bacterial enterocolitis

Disease-causing bacteria usually invade the small intestines and colon and cause enterocolitis (inflammation of the small intestine and colon). Bacterial enterocolitis is characterized by signs of inflammation (blood or pus in the stool, fever) and abdominal pain and diarrhea. Campylobacter jejuni is the most common bacterium that causes acute enterocolitis in the U.S. Other bacteria that cause enterocolitis include Shigella, Salmonella, and EPEC. These bacteria usually are acquired by drinking contaminated water or eating contaminated foods such as vegetables, poultry, and dairy products.

Enterocolitis caused by the bacterium Clostridium difficile is unusual because it often is caused by antibiotic treatment. Clostridium difficile is also the most common nosocomial infection (infection acquired while in the hospital) to cause diarrhea. Unfortunately, infection also is increasing among individuals who have neither taken antibiotics or been in the hospital.

E. coli O157:H7 is a strain of E. coli that produces a toxin that causes hemorrhagic enterocolitis (enterocolitis with bleeding). There was a famous outbreak of hemorrhagic enterocolitis in the U.S. traced to contaminated ground beef in hamburgers (hence it is also called hamburger colitis). Approximately 5% of patients infected with E. coli O157:H7, particularly children, can develop hemolytic uremic syndrome (HUS), a syndrome that can lead to kidney failure . Some evidence suggests that prolonged use of anti-diarrhea agents or use of antibiotics may increase the chance of developing HUS.

Parasites

Parasitic infections are not common causes of diarrhea in the U. S. Infection with Giardia lamblia occurs among individuals who hike in the mountains or travel abroad and is transmitted by contaminated drinking water. Infection with Giardia usually is not associated with inflammation; there is no blood or pus in the stool and little fever. Infection with amoeba (amoebic dysentery) usually occurs during travel abroad to undeveloped countries and is associated with signs of inflammation–blood or pus in the stool and fever.

Cryptosporidium is a diarrhea-producing parasite that is spread by contaminated water because it can survive chlorination. Cyclospora is a diarrhea-producing parasite that has been associated with contaminated raspberries from Guatemala.

Drugs

Drug-induced diarrhea is very common because many drugs cause diarrhea. The clue to drug-induced diarrhea is that the diarrhea begins soon after treatment with the drug is begun. The medications that most frequently cause diarrhea are antacids and nutritional supplements that contain magnesium. Other classes of medication that cause diarrhea include:

• nonsteroidal anti-inflammatory drugs (NSAIDs),
• chemotherapy medications,
• antibiotics,
• medications to control irregular heartbeats (antiarrhythmics), and
• medications for high blood pressure.

A few examples of specific medications that commonly cause diarrhea are:

• misoprostol (Cytotec),
• quinidine (Quinaglute, Quinidex),
• olsalazine (Dipentum),
• colchicine (Colchicine),
• metoclopramide (Reglan), and
• cisapride (Propulsid, Motilium).

What are common causes of chronic diarrhea?

Irritable bowel syndrome. The irritable bowel syndrome (IBS) is a functional cause of diarrhea or constipation. Inflammation does not typically exist in the affected bowel. (Nevertheless, recent information suggests that there MAY be a component of inflammation in IBS.) It may be caused by several different underlying problems, but it is believed that the most common cause is rapid passage of the intestinal contents through the colon.

Infectious diseases. There are a few infectious diseases that can cause chronic diarrhea, for example, Giardia lamblia . Patients with AIDS often have chronic infections of their intestines that cause diarrhea.

Bacterial overgrowth of the small intestine. Because of small intestinal problems, normal colonic bacteria may spread from the colon and into the small intestine. When they do, they are in a position to digest food that the small intestine has not had time to digest and absorb. The mechanism that leads to the development of diarrhea in bacterial overgrowth is not known.

Post-infectious. Following acute viral, bacterial or parasitic infections, some individuals develop chronic diarrhea. The cause of this type of diarrhea is not clear, but some of the individuals have bacterial overgrowth of the small intestine. This condition also is referred to as post-infectious IBS.

Inflammatory bowel disease (IBD). Crohn’s disease and ulcerative colitis, diseases causing inflammation of the small intestine and/or colon, commonly cause chronic diarrhea.

Colon cancer. Colon cancer can cause either diarrhea or constipation. If the cancer blocks the passage of stool, it usually causes constipation. Sometimes, however, there is secretion of water behind the blockage, and liquid stool from behind the blockage leaks around the cancer and results in diarrhea. Cancer, particularly in the distal part of the colon, can lead to thin stools. Cancer in the rectum can lead to a sense of incomplete evacuation.

Severe constipation. By blocking the colon, hardened stool can lead to the same problems as colon cancer, as discussed previously.

Carbohydrate (sugar) malabsorption. Carbohydrate or sugar malabsorption is an inability to digest and absorb sugars. The most well-recognized malabsorption of sugar occurs with lactase deficiency (also known as lactose or milk intolerance) in which milk products containing the milk sugar, lactose, lead to diarrhea. The lactose is not broken up in the intestine because of the absence of an intestinal enzyme, lactase, that normally breaks up lactose. Without being broken up, lactose cannot be absorbed into the body. The undigested lactose reaches the colon and pulls water (by osmosis) into the colon. This leads to diarrhea. Although lactose is the most common form of sugar malabsorption, other sugars in the diet also may cause diarrhea, including fructose and sorbitol.

Fat malabsorption. Malabsorption of fat is the inability to digest or absorb fat. Fat malabsorption may occur because of reduced pancreatic secretions that are necessary for normal digestion of fat (for example, due to pancreatitis or pancreatic cancer) or by diseases of the lining of the small intestine that prevent the absorption of digested fat (for example, celiac disease). Undigested fat enters the last part of the small intestine and colon where bacteria turn it into substances (chemicals) that cause water to be secreted by the small intestine and colon. Passage through the small intestine and colon also may be more rapid when there is malabsorption of fat.

Endocrine diseases. Several endocrine diseases (imbalances of hormones) may cause diarrhea, for example, an over-active thyroid gland (hyperthyroidism) and an under-active pituitary or adrenal gland (Addison’s disease).

Laxative abuse. The abuse of laxatives by individuals who want attention or to lose weight is an occasional cause of chronic diarrhea.

stomach ache

What are the complications of diarrhea?

Dehydration occurs when there is excessive loss of fluids and minerals (electrolytes) from the body due to diarrhea, with or without vomiting.

• Dehydration is common among adult patients with acute diarrhea who have large amounts of stool, particularly when the intake of fluids is limited by lethargy or is associated with nausea and vomiting.
• It also is common in infants and young children who develop viral gastroenteritis or bacterial infection.
• Patients with mild dehydration may experience only thirst and dry mouth.
• Moderate to severe dehydration may cause orthostatic hypotension with syncope (fainting upon standing due to a reduced volume of blood, which causes a drop in blood pressure upon standing), a diminished urine output, severe weakness, shock, kidney failure, confusion, acidosis (too much acid in the blood), and coma.

Electrolytes (minerals) also are lost with water when diarrhea is prolonged or severe, and mineral or electrolyte deficiencies may occur. The most common deficiencies occur with sodium and potassium. Abnormalities of chloride and bicarbonate also may develop.

Finally, there may be irritation of the anus due to the frequent passage of watery stool containing irritating substances.

When should the doctor be called for diarrhea?

Most episodes of diarrhea are mild and of short duration and do not need to be brought to the attention of a doctor. The doctor should be consulted when there is:

• High fever (temperature greater than 101 F)

• Moderate or severe abdominal pain or tenderness

• Bloody diarrhea that suggests severe intestinal inflammation

• Diarrhea in persons with serious underlying illness for whom dehydration may have more serious consequences, for example, persons with diabetes, heart disease, and AIDS

• Severe diarrhea that shows no improvement after 48 hours.

• Moderate or severe dehydration

• Prolonged vomiting that prevents intake of fluids orally

• Acute diarrhea in pregnant women because of concern for the health of the fetus

• Diarrhea that occurs during or immediately after completing a course of antibiotics because the diarrhea may represent antibiotic-associated infection with C. difficile that requires treatment

• Diarrhea after returning from developing countries or from camping in the mountains because there may be infection with Giardia (for which there is treatment)

• Diarrhea that develops in patients with chronic intestinal diseases such as colitis, or Crohn’s disease because the diarrhea may represent worsening of the underlying disease or a complication of the disease, both requiring treatment

• Acute diarrhea in an infant or young child in order to ensure the appropriate use of oral liquids (type, amount, and rate), to prevent or treat dehydration, and to prevent complications of inappropriate use of liquids such as seizures and abnormal blood electrolytes

• Chronic diarrhea

What tests are useful in the evaluation of diarrhea?

Acute diarrhea. Acute diarrhea usually requires few tests.

• Measurement of blood pressure in the upright and supine (lying) positions can demonstrate orthostatic hypotension and confirm the presence of dehydration. If moderate or severe dehydration or electrolyte deficiencies are likely, blood electrolytes can be measured.
• Examination of a small amount of stool under the microscope may reveal white blood cells indicating that intestinal inflammation is present and prompting further testing, particularly bacterial cultures of stool and examination of stool for parasites.
• If antibiotics have been taken within the previous two weeks, stool should be tested for the toxin of C. difficile.
• Testing stool or blood for viruses is performed only rarely, since there is no specific treatment for the viruses that cause gastroenteritis.
• If there has been recent travel to undeveloped countries or the mountains, stool may be examined under the microscope for Giardia and other parasites.
• There are also immunologic tests that can be done on samples of stool to diagnose infection with Giardia.

Chronic diarrhea. With chronic diarrhea, the focus usually shifts from dehydration and infection (with the exception of Giardia, which occasionally causes chronic infections) to the diagnosis of non-infectious causes of diarrhea. (See the prior discussion of common causes of chronic diarrhea.)

• This may require X-rays of the intestines (upper gastrointestinal series or barium enema), or endoscopy (esophagogastroduodenoscopy or EGD, or colonoscopy) with biopsies.
• Fat malabsorption can be diagnosed by measuring the fat in a 72 hour collection of stool.
• Sugar malabsorption can be diagnosed by eliminating the offending sugar from the diet or by performing a hydrogen breath test. Hydrogen breath testing also can be used to diagnose bacterial overgrowth of the small intestine.
• An under-active pituitary or adrenal gland and an overactive thyroid gland can be diagnosed by measuring blood levels of cortisol and thyroid hormone, respectively.
• Celiac disease can be diagnosed with blood tests and a biopsy of the small intestine.

How can dehydration be prevented and treated?

Oral rehydration solutions (ORS) are liquids that contain a carbohydrate (glucose or rice syrup) and electrolyte (sodium, potassium, chloride, and citrate or bicarbonate). Originally, the World Health Organization (WHO) developed the WHO-ORS to rapidly rehydrate victims of the severe diarrheal illness, cholera. The WHO-ORS solution contains glucose and electrolytes. The glucose in the solution is important because it forces the small intestine to quickly absorb the fluid and the electrolytes. The purpose of the electrolytes in the solution is the prevention and treatment of electrolyte deficiencies.

In the United States, convenient, premixed commercial ORS products that are similar to the WHO-ORS are available for rehydration and prevention of dehydration. Examples of these products are Pedialyte, Rehydralyte, Infalyte, and Resol.

Most of the commercially available ORS products in the U.S. contain glucose. Infalyte is the only one that contains rice carbohydrate instead of glucose. Most doctors believe that there are no important differences in effectiveness between glucose and rice carbohydrate.

Infants and young children. Most acute diarrhea in infants and young children is due to viral gastroenteritis and is usually short-lived. Antibiotics are not routinely prescribed for viral gastroenteritis. However, fever, vomiting, and loose stools can be symptoms of other childhood infections such as otitis media (infection of the middle ear), pneumonia, bladder infection, sepsis (bacterial infection in the blood) and meningitis. These illnesses may require early antibiotic treatment.

Infants with acute diarrhea also can quickly become severely dehydrated and therefore need early rehydration. For these reasons, sick infants with diarrhea should be evaluated by their pediatricians to identify and treat underlying infections as well as to provide instructions on the proper use of oral rehydration products.

Infants with moderate to severe dehydration usually are treated with intravenous fluids in the hospital. The pediatrician may decide to treat infants who are mildly dehydrated due to viral gastroenteritis at home with ORS.

Infants that are breast-fed or formula-fed should continue to receive breast milk during the rehydration phase of their illness if not prevented by vomiting. During, and for a short time after recovering from viral gastroenteritis, babies can be lactose intolerant due to a temporary deficiency of the enzyme, lactase (necessary to digest the lactose in milk) in the small intestine. Patients with lactose intolerance can develop worsening diarrhea and cramps when dairy products are introduced. Therefore, after rehydration with ORS, an undiluted lactose-free formula and diluted juices are recommended. Milk products can be gradually increased as the baby improves.

Older children and adults. During mild cases of diarrhea, diluted fruit juices, soft drinks containing sugar, sports drinks such as Gatorade, and water can be used to prevent dehydration. Caffeine and lactose containing dairy products should be temporarily avoided since they can aggravate diarrhea, the latter primarily in individuals with transient lactose intolerance. If there is no nausea and vomiting, solid foods should be continued. Foods that usually are well tolerated during a diarrheal illness include rice, cereal, bananas, potatoes, and lactose-free products.

ORS can be used for moderately severe diarrhea that is accompanied by dehydration in children older than 10 years of age and in adults. These solutions are given at 50 ml/kg over 4-6 hours for mild dehydration or 100 ml/kg over 6 hours for moderate dehydration. After rehydration, the ORS solution can be used to maintain hydration at 100 ml to 200 ml/kg over 24 hours until the diarrhea stops. Directions on the solution label usually state the amounts that are appropriate. After rehydration, older children and adults should resume solid food as soon as any nausea and vomiting subside. Solid food should begin with rice, cereal, bananas, potatoes, and lactose free and low fat products. The variety of foods can be expanded as the diarrhea subsides.

How is diarrhea treated?

Absorbents. Absorbents are compounds that absorb water. Absorbents that are taken orally bind water in the small intestine and colon and make diarrheal stools less watery. They also may bind toxic chemicals produced by bacteria that cause the small intestine to secrete fluid; however, the importance of toxin binding in reducing diarrhea is unclear.

The two main absorbents are attapulgite and polycarbophil, and they are both available without prescriptions.

Examples of products containing attapulgite are:

• Donnagel,
• Rheaban,
• Kaopectate Advanced Formula,
• Parepectolin, and
• Diasorb.

Examples of products containing polycarbophil are:

• Equalactin,
• Konsyl Fiber,
• Mitrolan, and
• Polycarb.

Equalactin is the antidiarrheal product containing attapulgite; however the laxative, Konsyl, also contains attapulgite. Attapulgite and polycarbophil remain in the intestine and, therefore, have no side effects outside of the gastrointestinal tract. They may occasionally cause constipation and bloating. One concern is that absorbents also can bind medications and interfere with their absorption into the body. For this reason, it often is recommended that medications and absorbents be taken several hours apart so that they are physically separated within the intestine.

Anti-motility medications. Anti-motility medications are drugs that relax the muscles of the small intestine and/or the colon. Relaxation results in slower flow of intestinal contents. Slower flow allows more time for water to be absorbed from the intestine and colon and reduces the water content of stool. Cramps, due to spasm of the intestinal muscles, also are relieved by the muscular relaxation.

The two main anti-motility medications are loperamide (Imodium), which is available without a prescription, and diphenoxylate (Lomotil), which requires a prescription. Both medications are related to opiates (for example, codeine ) but neither has the pain-relieving effects of opiates.

Loperamide (Imodium), though related to opiates, does not cause addiction.

Diphenoxylate is a man-made medication that at high doses can be addictive because of its opiate-like, euphoric (mood-elevating) effects. In order to prevent abuse of diphenoxylate and addiction, a second medication, atropine, is added to loperamide in Lomotil. If too much Lomotil is ingested, unpleasant side effects from too much atropine will occur.

Loperamide and diphenoxylate are safe and well-tolerated. There are some precautions, however, that should be observed.

• Anti-motility medications should not be used without a doctor’s guidance to treat diarrhea caused by moderate or severe ulcerative colitis, C. difficile colitis, and intestinal infections by bacteria that invade the intestine (for example, Shigella). Their use can lead to more serious inflammation and prolong the infections.

• Diphenoxylate can cause drowsiness or dizziness, and caution should be used if driving or performing tasks that require alertness and coordination are required.

• Anti-motility medications should not be used in children younger than two years of age.

• Most unimportant, acute diarrhea should improve within 72 hours. If symptoms do not improve or if they worsen, a doctor should be consulted before continuing treatment with anti-motility medications.

Bismuth compounds. Many bismuth-containing preparations are available around the world. Bismuth subsalicylate (Pepto-Bismol) is available in the United States. It contains two potentially active ingredients, bismuth and salicylate (aspirin). It is not clear how effective bismuth compounds are, except in traveler’s diarrhea and the treatment of H. pylori infection of the stomach where they have been shown to be effective. It also is not clear how bismuth subsalicylate might work. It is thought to have some antibiotic-like properties that affect bacteria that cause diarrhea. The salicylate is anti-inflammatory and could reduce secretion of water by reducing inflammation. Bismuth also might directly reduce the secretion of water by the intestine.

Pepto-Bismol is well-tolerated. Minor side effects include darkening of the stool and tongue. There are several precautions that should be observed when using Pepto-Bismol.

• Since it contains aspirin, patients who are allergic to aspirin should not take Pepto-Bismol.

• Pepto-Bismol should not be used with other aspirin-containing medications since too much aspirin may be ingested and lead to aspirin toxicity, the most common manifestation of which is ringing in the ears.

• The aspirin in Pepto-Bismol can accentuate the effects of anticoagulants, particularly warfarin (Coumadin), and lead to excessive bleeding. It also may cause abnormal bleeding in people who have a tendency to bleed because of genetic disorders or underlying diseases, for example, cirrhosis, that may cause abnormal bleeding.

• The aspirin in Pepto-Bismol can aggravate stomach and duodenal ulcer disease.

• Pepto-Bismol and aspirin-containing products should not be given to children and teenagers with chickenpox, influenza, and other viral infections because they may cause Reye’s syndrome. Reye’s syndrome is a serious illness affecting primarily the liver and brain that can lead to liver failure and coma, with a mortality rate of at least 20%.

• Pepto-Bismol should not be given to infants and children younger than two years of age.

When should antibiotics be used for diarrhea?

Most episodes of diarrhea are acute and of short duration and do not require antibiotics. Antibiotics are not even necessary for the most common bacterial infections that cause diarrhea. Antibiotics, however, often are used when (1) patients have more severe and persistent diarrhea, (2) patients have additional debilitating diseases such as heart failure, lung disease, and AIDS, (3) stool examination and testing discloses parasites, more serious bacterial infections (for example, Shigella), or C. difficile, and 4) traveler’s diarrhea.

Diarrhea At A Glance

• Diarrhea is an increase in the frequency of bowel movements, an increase in the looseness of stool or both.

• Diarrhea is caused by increased secretion of fluid into the intestine, reduced absorption of fluid from the intestine or rapid passage of stool through the intestine.

• Diarrhea can be defined absolutely or relatively. Absolute diarrhea is defined as more than five bowel movements a day or liquid stools. Relative diarrhea is defined as an increase in the number of bowel movements per day or an increase in the looseness of stools compared with an individual’s usual bowel habit.

• Diarrhea may be either acute or chronic, and each has different causes and treatments.

• Complications of diarrhea include dehydration, electrolytes (mineral) abnormalities, and irritation of the anus.

• Dehydration can be treated with oral rehydration solutions and, if necessary, with intravenous fluids.

• Tests that are useful in the evaluation of acute diarrhea include examination of stool for white blood cells and parasites, cultures of stool for bacteria, testing of stool for the toxin of C. difficile and blood tests for electrolyte abnormalities.

• Tests that are useful in the evaluation of chronic diarrhea include examination of stool for parasites, upper gastrointestinal X-rays (UGI series), barium enema, esophago-gastro-duodenoscopy (EGD) with biopsies, colonoscopy with biopsies, hydrogen breath testing, and measurement of fat in the stool.

• Diarrhea may be treated with absorbents, anti-motility medications, and bismuth compounds.

• Antibiotics should not be used in treating diarrhea unless there is a culture-proven bacterial infection that requires antibiotics, severe diarrhea that is likely to be infectious in origin, or when an individual has serious underlying diseases.

Pregnancy Tests

How do home pregnancy tests work?

Home pregnancy tests measure the presence of a telltale hormone called human chorionic gonadotropin (hCG) in your urine.

This hormone, produced by cells from the placenta, first enters your bloodstream when the fertilized egg implants in your uterus, about six days after fertilization. The amount of hCG in your body then increases rapidly over the next few weeks, doubling every two days or so.

How accurate are home pregnancy tests on the day you miss your period?

Most tests claim to be “greater than 99 percent accurate” and imply that you can use them as early as the day you miss your period, but a study published in 2004 in the American Journal of Obstetrics and Gynecology showed that this is misleading. Some tests may be able to detect the hormone in your urine at that point and give you a positive result, but most aren’t sensitive enough to guarantee you an accurate result.

Researchers at the University of New Mexico evaluated 18 tests and found that only one was consistently sensitive enough to detect the levels of hCG that most pregnant women were likely to have on the first day of their missed menstrual period. (The amount of hCG in the urine at this time can vary a great deal from one woman to another.) Most of the other tests were only sensitive enough to pick up about 16 percent of pregnancies that early.

The bottom line: You’re much more likely to get an accurate result if you wait a week after your expected period before testing.

How can these tests claim to be accurate so early in pregnancy?

According to Food and Drug Administration (FDA) regulations, a home pregnancy test can be called “greater than 99 percent accurate” if the manufacturer simply demonstrates that the test performs as well in the lab as an existing test more than 99 percent of the time. Since today’s home pregnancy tests are more sensitive than previous products, it’s not surprising that manufacturers are able to make this claim, but it has nothing to do with a test’s ability to detect pregnancy at the time of a missed period.

How can I tell which tests are the most sensitive?

It’s not easy. In the New Mexico study, First Response Early Result was the most sensitive test the researchers checked. But new products come out frequently, and other brands may make improvements to their products at any time.

Some package inserts provide information about a test’s sensitivity — that is, they report the lowest concentration of hCG (in mIU/ml, or milli—International Units per milliliter of urine) that the test can detect. For example, a pregnancy test that claims to be able to detect hCG at 20 mIU/ml should theoretically be more sensitive than one that claims to detect it at 50 mIU/ml.

Unfortunately, this information is often misleading because there are actually different kinds of hCG and these numbers won’t necessarily tell you how good a test is at detecting the kind that’s most relevant in early pregnancy.

How do I use a home pregnancy test?

First check the expiration date on the package and make sure it hasn’t expired, especially if you’ve had it around for a while. If you’ve been storing the test anywhere that gets moist or warm, like the bathroom, it may have deteriorated. If that’s the case, it’s better to throw it away and get a new one.

For best results, try testing first thing in the morning, when your urine is most concentrated. Read the directions carefully because they vary with different brands. Some require you to urinate in a cup and then, using a supplied dropper, place a small sample in a testing well. Others let you pee directly onto a stick. And some will let you do either.

The tests also vary in how they display the results: For example, some show pink or blue lines on the test strip, while others reveal a red plus or minus sign in a window. Most have a control indicator (often a second line or symbol) that’s supposed to indicate whether the test is valid.

If the control indicator doesn’t show up properly, the test may be faulty. If this happens to you, you can usually call the manufacturer and have them send you a new one, although it might not arrive soon enough for you to use that month.

If you have any questions about how to use a test, call the manufacturer’s toll-free number on the package instructions.

If the test shows a negative or a faintly positive result, wait another few days or a week and try again if you still haven’t gotten your period. One possibility is that you ovulated later in your cycle than you thought and took the test too early to get a positive result.

Whatever you do, don’t assume that one negative result means you’re not pregnant. If you don’t get your period as expected, remember that you might still have conceived. (It’s no time to go off on a drinking binge or do other things that are unsafe in pregnancy.) If you still haven’t gotten your period or a positive result in another week or so, make an appointment with your practitioner to find out why.

Is it possible to get a false positive result?

False positives — when the test says you’re pregnant but you’re not — are possible but uncommon.

You can get a false-positive result if you had a miscarriage or a pregnancy termination in the last eight weeks, have received a fertility drug containing hCG, or have certain medical conditions, such as an hCG-secreting tumor.

Using an expired or faulty test kit can also result in a false positive. In fact, the New Mexico study found two brands that gave occasional false-positive results.

If you get an early positive result and then get your period soon after, you may have had what’s sometimes called a “chemical pregnancy” — meaning that a fertilized egg implanted in your uterus and developed just enough to start producing hCG but then stopped developing for some reason. This happens with about 30 percent of fertilized eggs because they’re abnormal or otherwise incapable of developing into an embryo.

After a chemical pregnancy, you’ll go on to get your period, which may be a little heavier and a few days later than usual. When pregnancy tests were less sensitive than they are today, these very early losses were never identified. Some healthcare providers think that’s another good reason to wait until a week after your period is due to perform a home pregnancy test.

Note: An ectopic pregnancy can give you either a positive or negative result on a pregnancy test. Call your practitioner right away if you have abdominal pain or abnormal bleeding, no matter what a pregnancy test tells you.

How are home pregnancy tests different from tests performed in a medical office?

Often there’s no difference. Many healthcare providers use a urine pregnancy test, just as you would at home.

Blood tests for pregnancy are usually only used to find out exactly how much hCG is in your blood or what’s happening to the level over time — to see whether you’re miscarrying, for example.

Where can I buy a home pregnancy test?

You can buy one without a prescription at our online store AnyOTC.com.

Bloody stools

Bloody or tarry stools – Overview

Alternative Names

Stools – bloody; Hematochezia; Melena; Stools – black or tarry

Definition of Bloody or tarry stools:

Bloody stools often indicate an injury or disorder in the digestive tract. Your doctor may use the term “melena” to describe black, tarry, and foul-smelling stools or “hematochezia” to describe red- or maroon-colored stools.

Considerations:

Blood in the stool may come from anywhere along your digestive tract, from mouth to anus. It may be present in such small amounts that you cannot actually see it, but it is only detectable by a fecal occult blood test. When there IS enough blood to change the appearance of your stools, the doctor will want to know the exact color to help find the site of bleeding. To make a diagnosis, your doctor may use endoscopy or special x-ray studies.

A black stool usually means that the blood is coming from the upper part of the gastrointestinal (GI) tract. This includes the esophagus, stomach, and the first part of the small intestine. Blood will typically look like tar after it has been exposed to the body’s digestive juices. Stomach ulcers or inflammation caused by ibuprofen, naproxen, or aspirin are common causes of upper GI bleeding.

Maroon-colored stools or bright red blood usually suggests that the blood is coming from the lower part of the GI tract (large bowel, rectum, or anus). Hemorrhoids and diverticulosis (an abnormal pouch in the colon) are the most common causes of lower GI bleeding. Abnormal collections of blood vessels called arteriovenous malformations (AVMs) and tumors in the intestine may also cause lower GI bleeding. However, sometimes massive or rapid bleeding in the stomach causes bright red stools.

Consuming black licorice, lead, iron pills, bismuth medicines like Pepto-Bismol, or blueberries can also cause black stools. Beets and tomatoes can sometimes make stools appear reddish. In these cases, your doctor can test the stool with a chemical to rule out the presence of blood.

Brisk bleeding in the esophagus or stomach (such as with peptic ulcer disease), can also cause you to vomit blood.

Common Causes:

Upper GI tract (usually black stools):

• Abnormal blood vessels (vascular malformation)
• A tear in the esophagus from violent vomiting (Mallory-Weiss tear)
• Bleeding stomach or duodenal ulcer
• Inflammation of the stomach lining (gastritis)
• Lack of proper blood flow to the intestines (bowel ischemia)
• Trauma or foreign body
• Widened, overgrown blood vesels (esophageal and stomach varices)

Lower GI tract (usually maroon or bright red, bloody stools):

• Anal fissures
• Bowel ischemia
• Colon polyps or colon cancer
• Diverticulosis
• Hemorrhoids
• Inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis)
• Intestinal infection (such as bacterial enterocolitis)
• Small bowel tumor
• Trauma or foreign body
• Vascular malformation

Treatment

Call your health care provider if:

Call your doctor immediately if you notice blood or changes in the color of your stool. Even if you think that hemorrhoids are causing blood in your stool, your doctor should examine you in order to make sure that there is no other, more serious cause present at the same time.

In children, a small amount of blood in the stool is usually not serious. The most common causes are constipation and milk allergies. But it is still worth reporting to your doctor, even if no evaluation is necessary.

What to expect at your health care provider’s office:

Your doctor will take a medical history and perform a physical examination, focusing on your abdomen and rectum.

The following questions may be included in the history to better understand the possible causes of your bloody or dark stools:

• Are you taking blood thinners or NSAIDs (ibuprofen, naproxen, aspirin)
• Have you had any trauma to the abdomen or rectum, or have you swallowed a foreign object accidentally?
• Have you eaten black licorice, lead, Pepto-Bismol, or blueberries?
• Have you had more than one episode of blood in your stool? Is every stool this way?
• Have you lost any weight recently?
• Is there blood on the toilet paper only?
• What color is the stool?
• When did it develop?
• What other symptoms are present — abdominal pain, vomiting blood, bloating, excessive gas, diarrhea, or fever?

Treatment depends on the cause and severity of the bleeding. For serious bleeding, you may be admitted to a hospital for monitoring and evaluation. If there is massive bleeding, you will be monitored in an intensive care unit. Emergency treatment may include a blood transfusion.

The following diagnostic tests may be performed:

• Angiography
• Barium studies
• Bleeding scan
• Blood studies, including a CBC and differential, serum chemistries, clotting studies
• Colonoscopy
• Esophagogastroduodenoscopy or EGD
• Stool culture
• Tests for the presence of Helicobacter pylori infection
• X-rays of the abdomen

Prevention:

• Eat vegetables and foods rich in natural fiber and low in saturated fat. These may reduce constipation, hemorrhoids, diverticulosis, and colon cancer.
• Avoid prolonged, excessive use of anti-inflammatory drugs like ibuprofen, naproxen, and aspirin. These can irritate the stomach and cause ulcers.
• If you drink alcohol, do so in moderation. Large amounts of alcohol can irritate the lining of the esophagus and stomach.
• DON’T smoke. It is linked to peptic ulcers and cancers of the GI tract.
• Try to avoid too much stress — a possible factor in peptic ulcer disease.
• Your doctor may recommend antibiotics and other medications to prevent a future bleeding ulcer if you have been diagnosed with a helicobacter infection (often related to ulcers).

The earlier you detect colon cancer, the more likely that treatment will be successful. The American Cancer Society recommends one or more of the following screening tests after age 50 for early detection of colon cancer and pre-cancer:

• Fecal occult blood testing every year.
• Flexible sigmoidoscopy or barium enema every five years.
• Colonoscopy every 10 years.

Screening tests should be started earlier if you have a family history of colon cancer or polyps. Tests should also be performed more often if you have had polyps, colon cancer, or inflammatory bowel disease.

Ring Worm

What is ringworm of the skin?

Ringworm of the skin is an infection caused by a fungus.

Jock itch is a form of ringworm that causes an itchy rash on the skin of your groin area. It is much more common in men than in women. Most people get it by accidentally spreading the fungus that causes athlete’s foot to their own groin area.

What causes ringworm?

Ringworm is not caused by a worm. It is caused by a fungus. The kinds of fungi (plural of fungus) that cause ringworm live and spread on the top layer of the skin and on the hair. They grow best in warm, moist areas, such as locker rooms and swimming pools, and in skin folds.

Ringworm is contagious. It spreads when you have skin-to-skin contact with a person or animal that has it. It can also spread when you share things like towels, clothing, or sports gear.

You can also get ringworm by touching an infected dog or cat, although this form of ringworm is not common.

What are the symptoms?

Ringworm of the skin usually causes a very itchy rash. It often makes a pattern in the shape of a ring, but not always. Sometimes it is just a red, itchy rash.

Jock itch is a rash in the skin folds of the groin. It may also spread to the inner thighs or buttocks.

Ringworm of the hand looks like athlete’s foot. The skin on the palm of the hand gets thick, dry, and scaly, while skin between the fingers may be moist and have open sores.

How is ringworm of the skin diagnosed?

If you have a ring-shaped rash, you very likely have ringworm. Your doctor will be able to tell for sure. He or she will probably look at a scraping from the rash under a microscope to check for the ringworm fungus.

How is it treated?

Most ringworm of the skin can be treated at home with creams you can buy without a prescription. Your rash may clear up soon after you start treatment, but it’s important to keep using the cream for as long as the label or your doctor says. This will keep the infection from coming back. If the cream doesn’t work, your doctor can prescribe pills that will kill the fungus.

If ringworm is not treated, your skin could blister, and the cracks could become infected with bacteria. If this happens, you will need antibiotics.

If your child is being treated for ringworm, you don’t have to keep him or her out of school or day care.

Different medications for ringworms are available at our online store anyOTC.com

Can you prevent ringworm?

To prevent ringworm:

• Don’t share clothing, sports gear, towels, or sheets. If you think you have been exposed to ringworm, wash your clothes in hot water with special anti-fungus soap.
• Wear slippers or sandals in locker rooms and public bathing areas.
• Shower and shampoo well after any sport that includes skin-to-skin contact.
• Wear loose-fitting cotton clothing. Change your socks and underwear at least once a day.
• Keep your skin clean and dry. Always dry yourself completely after showers or baths.
• If you have athlete’s foot, put your socks on before your underwear so that fungi do not spread from your feet to your groin.
• Take your pet to the vet if it has patches of missing hair, which could be a sign of a fungal infection.

Ringworm can come back. To prevent this, use talcum or other drying powder on the affected area every day.

If you or someone in your family has symptoms, it is important to treat ringworm right away to keep other family members from getting it.

Jock Itch

Jock Itch (Tinea Cruris)

The term “jock itch” typically describes an itchy rash in a man’s groin. Although there are many causes of jock itch, this term has become synonymous with tinea cruris, a common fungal infection that affects the groin and inner thighs of men and women. Tinea is the name of the fungus; cruris comes from the Latin word for leg.

Jock itch can develop when tight garments trap moisture and heat. This creates an environment in which fungi multiply and flourish. Athletes often get jock itch. It occurs more commonly in men, but can affect women as well. The jock itch fungus may cause a rash on the upper and inner thighs, the armpits, and the area just underneath the breasts. Many people with tinea cruris also have athlete’s foot. Athlete’s foot is called tinea pedis.

Symptoms

A flat, red, itchy rash first appears high on the inner side of one or both thighs. It spreads outward in a ringlike circular pattern while the center clears up partially. The border is sharply marked, slightly raised and often beefy red in color. Jock itch can spread to the pubic and genital regions and sometimes to the buttocks.

Diagnosis

Your doctor often can make the diagnosis just by looking at the rash. Your doctor may gently scrape the skin to get a sample to look for fungi under the microscope. With stubborn cases, your doctor may send the sample to a laboratory to pinpoint the fungus that’s causing the trouble. Other causes of a rash in the groin include yeast infection of the skin, seborrheic dermatitis and psoriasis.

Expected Duration

Jock itch usually can be treated within weeks, although it commonly comes back. Treatment for chronic (long-lasting) infections may last one or two months.

Prevention

The healthier you are, the less likely you are to get a fungal infection. Remaining healthy through diet, rest and exercise is the first step in avoiding fungal infection.

Here are other steps you can take to remain fungus-free:

• Keep your body clean.
• Dry yourself well after showers and baths.
• Shower immediately after athletic activities.
• Wear loose clothing whenever possible.
• Do not share clothing or towels with others; wash towels frequently.
• Clean exercise equipment before use.
• Wear sandals in the shower area at the gym and swimming pool.

Treatment

Most likely, your doctor will prescribe a topical antifungal treatment for you to apply once or twice a day for at least two weeks. If you have athlete’s foot, your doctor should treat that as well. Untreated athlete’s foot can cause jock itch to return.

Different antifungal creams are available at our online store anyOTC.com

Because jock itch commonly comes back, you need to be extra cautious. You can apply powder daily to help keep the area dry. The itching can be alleviated with an over-the-counter treatment such as Sarna lotion. You also should avoid hot baths and tight-fitting clothing. Men should wear boxer shorts rather than briefs.

When To Call a Professional

Call your doctor whenever you develop a skin rash.

Prognosis

Treatment for jock itch is quick and usually effective, but the condition often comes back. The following people should be especially vigilant to prevent the problem from returning:

• Athletes
• People with fungal infections that affect other parts of the body (such as athlete’s foot)
• People who wear tight clothing
• People with damaged or altered immune systems

Athlete’s Foot

What is athlete’s foot?

Athlete’s foot is a very common skin infection of the foot caused by fungus. The fungus that commonly causes athlete’s foot is called Trichophyton. When the feet or other areas of the body stay moist, warm, and irritated, this fungus can thrive and infect the upper layer of the skin. Fungal infections can occur anywhere on the body, including the scalp, trunk, extremities (arms and legs), hands, feet, nails, groin, and other areas.

Athlete’s foot is caused by the ringworm fungus (“tinea” in medical jargon). Athlete’s foot is also called tinea pedis. The fungus that causes athlete’s foot can be found on many locations, including floors in gyms, locker rooms, swimming pools, nail salons, and in socks and clothing. The fungus can also be spread directly from person to person or by contact with these objects.

However, without proper growing conditions (a warm, moist environment), the fungus may not easily infect the skin. Up to 70% of the population may have athlete’s foot at some time during their lives.

What are the symptoms of athlete’s foot?

The symptoms of athlete’s foot typically include various degrees of itching and burning. The skin may frequently peel, and in particularly severe cases, there may be some cracking, pain, and bleeding as well. Some people have no symptoms at all and do not know they have an infection.

What does athlete’s foot look like?

Athlete’s foot may look like red, peeling, dry skin areas on one or both soles of the feet. Sometimes the dry flakes may spread onto the sides and tops of the feet. Most commonly the rash is localized to just the soles of the feet. The space between the fourth and fifth toes also may have some moisture, peeling, and dry flakes.

There are three common types of athlete’s foot.

1. soles of the feet, also called “moccasin” type
2. between the toes, also called “interdigital” type



3. inflammatory type or blistering

Unusual cases may look like small or large blisters of the feet (called bullous tinea pedis), thick patches of dry, red skin, or calluses with redness. Sometimes, it may look like just mild dry skin without any redness or inflammation.

Athlete’s foot may present as a rash on one or both feet and even involve the hand. This is a very common presentation of athlete’s foot. Hand fungal infections are called tinea manuum. The exact cause of why the infection commonly only affects one hand is not known.

Athlete’s foot may also be seen along with ringworm of the groin (especially in men) or hand(s). It is helpful to examine the feet whenever there is a fungal groin rash called tinea cruris. It is important to treat all areas of fungal infection at one time to avoid re-infection.

Is athlete’s foot contagious?

Athlete’s foot may be contagious from person to person, but it is not always contagious. Some people may be more susceptible to the fungus that causes athlete’s foot while others are more resistant. There are many households where two people (often husband and wife or siblings) using the same showers and bathroom for years have not transmitted the fungus between them. The exact cause of this predisposition or susceptibility to fungal infections is unknown. Some people just seem more prone to fungal skin infections than others.

What else causes foot rashes?

There are many possible causes of foot rashes. Athlete’s foot is one of the more common causes. Additional causes include irritant or contact dermatitis, allergic rashes from shoes or other creams, dyshidrotic eczema (skin allergy rash), psoriasis, keratodermia blenorrhagicum, yeast infections, and bacterial infections.

Your physician can perform a simple test called a KOH, or potassium hydroxide for microscopic fungal examination, in the office or laboratory to confirm the presence of a fungal infection. This test is performed using small flakes of skin that are examined under the microscope. Many dermatologists perform this test in their office with results available within minutes. Rarely, a small piece of skin may be removed and sent for biopsy to help confirm the diagnosis.

What is the treatment for athlete’s foot?

The treatment of athlete’s foot can be divided into two parts. The first, and most important part, is to make the infected area less suitable for the athlete’s foot fungus to grow. This means keeping the area clean and dry.

Buy shoes that are leather or other breathable material. Shoe materials, such as vinyl, that don’t breathe cause your feet to remain moist, providing an excellent area for the fungus to breed. Likewise, absorbent socks like cotton that wick water away from your feet may help.

Powders, especially medicated powders (such as with miconazole or tolnaftate), can help keep your feet dry. Finally, your feet can be soaked in a drying solution of aluminum acetate (Burrow’s solution or Domeboro’s solution). A homemade remedy of dilute white vinegar soaks using one part vinegar and roughly four parts water, once or twice a day as 10-minute foot soaks may aid in treatment.

The second part of treatment is the use of antifungal creams and washes. Many medications are available, including miconazole, clotrimazole, terbinafine (Lamisil) sprays and creams, and ketoconazole shampoo and cream, etc. Ask your health-care professional or pharmacist for a recommendation. Treatment for athlete’s foot should generally be continued for four weeks, or at least one week after all of the skin symptoms have cleared.

More advanced or resistant cases of athlete’s foot may require a two- to three-week course of an oral (pill) antifungal like terbinafine, itraconazole (Sporanox), or fluconazole (Diflucan). Laboratory blood tests to make sure there is no liver disease may be required before taking these pills.

Topical corticosteroid creams can act as a fertilizer for fungus and may actually worsen fungal skin infections. These topical steroid medications have no role in treating athlete’s foot.

If the fungal infection has spread to the toenails, the nails must also be treated to avoid re-infection of the feet. Often, the nails are initially ignored only to find the athlete’s foot keeps recurring. It is important to treat all the visible fungus at the same time. Effective nail fungus treatment may be more intensive and require prolonged courses (three to four months) of oral antifungal medications.

Different medications are available at our online store anyOTC.com

When should I seek medical care?

If you notice any redness, increased swelling, bleeding, or if your infection is not clearing up, see your health-care practitioner. If a bacterial infection is also occurring, an antibiotic pill may be necessary. If you have fungal nail involvement, are diabetic, or have a compromised immune system, you should also see your physician for treatment.

What are possible complications of athlete’s foot?

Untreated, athlete’s foot can potentially spread to other body parts or other people including family members. Fungus may spread locally to the legs, toenails, hands, fingernails, and essentially any body area.

This type of fungus generally likes to live in the skin, hair, and nails. It does not invade deep, go into body organs, or go into the blood system.

Fungal infections of the nails are called tinea unguium or onychomycosis. Nail fungus may be very difficult to treat. Antifungal pills may be required in cases of more advanced toenail fungal infections.

People with diabetes, HIV/AIDS, cancer, or other immune problems may be more prone to all kinds of infections, including fungus.

When the skin is injured by fungus, the natural protective skin barrier is broken. Bacteria and yeasts can then invade the broken skin. Bacteria can cause a bad smell. Bacterial infection of the skin and resulting inflammation is known as cellulitis. This is especially likely to occur in the elderly, individuals with diabetes, chronic leg swelling, or who have had veins removed (such as for heart bypass surgery). Bacterial skin infections also occur more frequently in patients with impaired immune systems.

Urinary Tract Infections

Urinary tract infection introduction

Urinary tract infections are a serious health problem affecting millions of people each year.

Infections of the urinary tract are the second most common type of infection in the body. Urinary tract infections (UTIs) account for about 8.3 million doctor visits each year. Women are especially prone to UTIs for reasons that are not yet well understood. One woman in five develops a UTI during her lifetime. UTIs in men are not as common as in women but can be very serious when they do occur.

The urinary system consists of the kidneys, ureters, bladder, and urethra. The key elements in the system are the kidneys, a pair of purplish-brown organs located below the ribs toward the middle of the back. The kidneys remove excess liquid and wastes from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce a hormone that aids the formation of red blood cells. Narrow tubes called ureters carry urine from the kidneys to the bladder, a sack-like organ in the lower abdomen. Urine is stored in the bladder and emptied through the urethra.

The average adult passes about a quart and a half of urine each day. The amount of urine varies, depending on the fluids and foods a person consumes. The volume formed at night is about half that formed in the daytime.

What are the causes of UTI?

Normally, urine is sterile. It is usually free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. The urethra is the tube that carries urine from the bladder to outside the body. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon.

In many cases, bacteria first travel to the urethra. When bacteria multiply, an infection can occur. An infection limited to the urethra is called urethritis. If bacteria move to the bladder and multiply, a bladder infection, called cystitis, results. If the infection is not treated promptly, bacteria may then travel further up the ureters to multiply and infect the kidneys. A kidney infection is called pyelonephritis.

Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners.

The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections still occur.

Who is at risk?

Some people are more prone to getting a UTI than others. Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection. An enlarged prostate gland also can slow the flow of urine, thus raising the risk of infection.

A common source of infection is catheters, or tubes, placed in the urethra and bladder. A person who cannot void or who is unconscious or critically ill often needs a catheter that stays in place for a long time. Some people, especially the elderly or those with nervous system disorders who lose bladder control, may need a catheter for life. Bacteria on the catheter can infect the bladder, so hospital staff take special care to keep the catheter clean and remove it as soon as possible.

People with diabetes have a higher risk of a UTI because of changes in the immune system. Any other disorder that suppresses the immune system raises the risk of a urinary infection.

UTIs may occur in infants, both boys and girls, who are born with abnormalities of the urinary tract, which sometimes need to be corrected with surgery. UTIs are more rare in boys and young men. In adult women, though, the rate of UTIs gradually increases with age. Scientists are not sure why women have more urinary infections than men. One factor may be that a woman’s urethra is short, allowing bacteria quick access to the bladder. Also, a woman’s urethral opening is near sources of bacteria from the anus and vagina. For many women, sexual intercourse seems to trigger an infection, although the reasons for this linkage are unclear.

According to several studies, women who use a diaphragm are more likely to develop a UTI than women who use other forms of birth control. Recently, researchers found that women whose partners use a condom with spermicidal foam also tend to have growth of E. coli bacteria in the vagina.

Recurrent infections

Many women suffer from frequent UTIs. Nearly 20 percent of women who have a UTI will have another, and 30 percent of those will have yet another. Of the last group, 80 percent will have recurrences.

Usually, the latest infection stems from a strain or type of bacteria that is different from the infection before it, indicating a separate infection. Even when several UTIs in a row are due to E. coli, slight differences in the bacteria indicate distinct infections.

Research funded by the National Institutes of Health (NIH) suggests that one factor behind recurrent UTIs may be the ability of bacteria to attach to cells lining the urinary tract. A recent NIH-funded study found that bacteria formed a protective film on the inner lining of the bladder in mice. If a similar process can be demonstrated in humans, the discovery may lead to new treatments to prevent recurrent UTIs. Another line of research has indicated that women who are “non-secretors” of certain blood group antigens may be more prone to recurrent UTIs because the cells lining the vagina and urethra may allow bacteria to attach more easily. Further research will show whether this association is sound and proves useful in identifying women at high risk for UTIs.

Infections in pregnancy

Pregnant women seem no more prone to UTIs than other women. However, when a UTI does occur in a pregnant woman, it is more likely to travel to the kidneys. According to some reports, about 2 to 4 percent of pregnant women develop a urinary infection. Scientists think that hormonal changes and shifts in the position of the urinary tract during pregnancy make it easier for bacteria to travel up the ureters to the kidneys. For this reason, many doctors recommend periodic testing of urine during pregnancy.

What are the symptoms of UTI?

Not everyone with a UTI has symptoms, but most people get at least some symptoms. These may include a frequent urge to urinate and a painful, burning feeling in the area of the bladder or urethra during urination. It is not unusual to feel bad all over — tired, shaky, washed out — and to feel pain even when not urinating. Often women feel an uncomfortable pressure above the pubic bone, and some men experience a fullness in the rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The urine itself may look milky or cloudy, even reddish if blood is present. Normally, a UTI does not cause fever if it is in the bladder or urethra. A fever may mean that the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting.

In children, symptoms of a urinary infection may be overlooked or attributed to another disorder. A UTI should be considered when a child or infant seems irritable, is not eating normally, has an unexplained fever that does not go away, has incontinence or loose bowels, or is not thriving. Unlike adults, children are more likely to have fever and no other symptoms. This can happen to both boys and girls. The child should be seen by a doctor if there are any questions about these symptoms, especially a change in the child’s urinary pattern.

How is a UTI diagnosed?

To find out whether you have a UTI, your doctor will test a sample of urine for pus and bacteria. You will be asked to give a “clean catch” urine sample by washing the genital area and collecting a “midstream” sample of urine in a sterile container. This method of collecting urine helps prevent bacteria around the genital area from getting into the sample and confusing the test results. Usually, the sample is sent to a laboratory, although some doctors’ offices are equipped to do the testing.

In the urinalysis test, the urine is examined for white and red blood cells and bacteria. Then the bacteria are grown in a culture and tested against different antibiotics to see which drug best destroys the bacteria. This last step is called a sensitivity test.

Some microbes, like Chlamydia and Mycoplasma, can be detected only with special bacterial cultures. A doctor suspects one of these infections when a person has symptoms of a UTI and pus in the urine, but a standard culture fails to grow any bacteria.

When an infection does not clear up with treatment and is traced to the same strain of bacteria, the doctor may order some tests to determine if your system is normal. One of these tests is an intravenous pyelogram, which gives x-ray images of the bladder, kidneys, and ureters. An opaque dye visible on x-ray film is injected into a vein, and a series of x-rays is taken. The film shows an outline of the urinary tract, revealing even small changes in the structure of the tract.

If you have recurrent infections, your doctor also may recommend an ultrasound exam, which gives pictures from the echo patterns of soundwaves bounced back from internal organs. Another useful test is cystoscopy. A cystoscope is an instrument made of a hollow tube with several lenses and a light source, which allows the doctor to see inside the bladder from the urethra.

How is UTI treated?

UTIs are treated with antibacterial drugs. The choice of drug and length of treatment depend on the patient’s history and the urine tests that identify the offending bacteria. The sensitivity test is especially useful in helping the doctor select the most effective drug. The drugs most often used to treat routine, uncomplicated UTIs are trimethoprim (Trimpex), trimethoprim/sulfamethoxazole (Bactrim, Septra, Cotrim), amoxicillin (Amoxil, Trimox, Wymox), nitrofurantoin (Macrodantin, Furadantin), and ampicillin (Omnipen, Polycillin, Principen, Totacillin). A class of drugs called quinolones includes four drugs approved in recent years for treating UTI. These drugs include ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro), and trovafloxin (Trovan).

Often, a UTI can be cured with 1 or 2 days of treatment if the infection is not complicated by an obstruction or other disorder. Still, many doctors ask their patients to take antibiotics for a week or two to ensure that the infection has been cured. Single-dose treatment is not recommended for some groups of patients, for example, those who have delayed treatment or have signs of a kidney infection, patients with diabetes or structural abnormalities, or men who have prostate infections. Longer treatment is also needed by patients with infections caused by Mycoplasma or Chlamydia, which are usually treated with tetracycline, trimethoprim/sulfamethoxazole (TMP/SMZ), or doxycycline. A followup urinalysis helps to confirm that the urinary tract is infection-free. It is important to take the full course of treatment because symptoms may disappear before the infection is fully cleared.

Severely ill patients with kidney infections may be hospitalized until they can take fluids and needed drugs on their own. Kidney infections generally require several weeks of antibiotic treatment. Researchers at the University of Washington found that 2-week therapy with TMP/SMZ was as effective as 6 weeks of treatment with the same drug in women with kidney infections that did not involve an obstruction or nervous system disorder. In such cases, kidney infections rarely lead to kidney damage or kidney failure unless they go untreated.

Various drugs are available to relieve the pain of a UTI. A heating pad may also help. Most doctors suggest that drinking plenty of water helps cleanse the urinary tract of bacteria. During treatment, it is best to avoid coffee, alcohol, and spicy foods. And one of the best things a smoker can do for his or her bladder is to quit smoking. Smoking is the major known cause of bladder cancer.

Bedsores

Definition

Bedsores, also called decubitus ulcers, pressure ulcers, or pressure sores, begin as tender, inflamed patches that develop when a person’s weight rests against a hard surface, exerting pressure on the skin and soft tissue over bony parts of the body. For example, skin covering a weight-bearing part of the body, such as a knee or hip, is pressed between a bone and a bed, chair, another body part, splint, or other hard object. This is most likely to happen when the person is confined to a bed or wheelchair for long periods of time and is relatively immobile. Usually, mobile individuals, when either conscious or unconscious, will receive nerve signals from the compressed part of the body and will automatically move to relieve the pressure. Pressure sores do not usually develop in people with normal mobility and mental alertness. However, people compromised through acute illness, heavy sedation, unconsciousness, or diminished mental functioning, may not receive signals to move, and as a result of the constant pressure, tissue damage may progress to bedsores in these individuals.

Demographics

Each year, about one million people in the United States develop bedsores at a treatment cost of $1 billion. Pressure sores are most often found in elderly patients; records show that two thirds of all bedsores occur in people over age 70. People who are neurologically impaired, such as those with spinal injuries or paralysis, are also at high risk. Pressure sores have been noted as a direct cause of death in about 8% of paraplegics.

Description

Bedsores range from mild inflammation to ulceration (breakdown of tissue) and deep wounds that involve muscle and bone. This painful condition usually starts with shiny red skin that quickly blisters and deteriorates into open sores. These sores become a target for bacterial contamination and will often harbor life-threatening infection. Bedsores are not contagious or cancerous, although the most serious complication of chronic bedsores is the development of malignant degeneration, which is a type of cancer.

Bedsores develop as a result of pressure that cuts off the flow of blood and oxygen to tissue. Constant pressure pinches off capillaries, the tiny blood vessels that deliver oxygen and nutrients to the skin. If the skin is deprived of essential oxygen and nutrients (a condition known as ischemia) for even as little as an hour, tissue cells can die (anoxia) and bedsores can form. Even the slightest rubbing, called shear, or friction between a hard surface and skin stretched over bones, can cause minor pressure ulcers. They can also develop when a patient stretches or bends blood vessels by slipping into a different position in a bed or chair.

Since urine, feces, or other moisture increases the risk of skin infection, people who suffer from incontinence, as well as immobility, have a greater than average risk of developing bedsores.

Unfortunately, people who have been successfully treated for bedsores have a 90% chance of developing them again. While the pressure sores themselves can usually be cured, about 60,000 deaths per year are attributed to complications caused by bedsores. They can be slow to heal, particularly when the patient’s overall status may be weakened. Without proper treatment, bedsores can lead to:

• gangrene (tissue death)
• osteomyelitis (infection of the bone beneath the bedsore)
• sepsis (a poisoning of tissue or the whole body from bacterial infection)
• other localized or systemic infections that slow the healing process, increase the cost of treatment, lengthen hospital or nursing home stays, or cause death

Bedsores are most apt to develop on bony parts of the body, including:

• ankles
• back of the head
• heels
• hips
• knees
• lower back
• shoulder blades
• spine

Although impaired mobility is a leading factor in the development of pressure sores, the risk is also increased by illnesses and conditions that weaken muscle and soft tissue, or that affect blood circulation and the delivery of oxygen to body tissue, leaving skin thinner and more vulnerable to breakdown and subsequent infection. These conditions include:

• atherosclerosis (hardening of arteries) that restricts blood flow
• diabetes
• diminished sensation or lack of feeling, unable to feel pain
• heart problems
• incontinence (inability to control bladder or bowel movements)
• malnutrition
• obesity
• paralysis
• poor circulation
• infection
• prolonged bed rest, especially in unsanitary conditions or with wet or wrinkled sheets
• spinal cord injury

Diagnosis/Preparation

Physical examination, medical history, and patient and caregiver observations are the basis of diagnosis. Special attention must be paid to physical or mental problems, such as an underlying disease, incontinence, or confusion that could complicate a patient’s recovery. Nutritional status and smoking history should also be noted.

The National Pressure Ulcer Advisory Panel (NPUAP) recommends classification of bedsores in four stages of ulceration based primarily on the depth of a sore at the time of examination. This helps standardize the language and encourages effective communication of medical personnel caring for patients with bedsores. The NPUAP advises that not all bedsores follow the stages directly from I to IV. The four most widely accepted stages are described as:

• Stage I: intact skin with redness (erythema) and sometimes with warmth.
• Stage II: partial-thickness loss of skin, an abrasion, swelling, and possible blistering or peeling of skin.
• Stage III: full-thickness loss of skin, open wound (crater), and possible exposed under layer.
• Stage IV: full-thickness loss of skin and underlying tissue, extends into muscle, bone, tendon, or joint. Possible bone destruction, dislocations, or pathologic fractures (not caused by injury).

In addition to observing the depth of the wound, the presence or absence of wound drainage and foul odors, or any debris in the wound, such as pieces of dead skin tissue or other material, should also be noted. Any condition that could likely contaminate the wound and cause infection, such as the presence of urine or feces from incontinence, should be noted as well.

A doctor should be notified whenever a person:

• will be bedridden or immobilized for an extended time period
• is very weak or unable to move
• develops redness (inflammation) and warmth or peeling on any area of skin

Immediate medical attention is required whenever:

• skin turns black or becomes inflamed, tender, swollen, or warm to the touch
• the patient develops a fever during treatment
• a bedsore contains pus or has a foul-smelling discharge

Prompt medical attention can prevent surface pressure sores from deepening into more serious infections. The first step is always to reduce or eliminate the pressure that is causing bedsores. For minor bedsores, stages I and II, treatment involves relieving pressure, keeping the wound clean and moist, and keeping the area around the ulcer clean and dry. This is often accomplished with saline washes and the use of sterile medicated gauze dressings that both absorb the wound drainage and fight infection-causing bacteria. Antiseptics, harsh soaps, and other skin cleansers can damage new tissue and should be avoided. Only saline solution should be used to cleanse bedsores whenever fresh non-stick dressings are applied.

The patient’s doctor may prescribe infection-fighting antibiotics, special dressings or drying agents, and/or lotions or ointments to be applied to the wound in a thin film three or four times a day. Warm whirlpool treatments are sometimes recommended for sores on the arm, hand, foot, or leg.

Typically, with the removal or reduction of pressure in conjunction with proper treatment and attention to the patient’s general health, including good nutrition, bedsores should begin to heal two to four weeks after treatment begins.

Surgical options are often considered for non-healing wounds. When deep wounds are not responding well to standard medical procedures, consultation with a plastic surgeon may be needed to determine if reconstructive surgery is the best possible treatment. In a procedure called debriding, a scalpel may be used to remove dead tissue or other debris from Stage III and IV wounds. A surgical procedure called urinary (or fecal) diversion may also be used with incontinent patients to divert the flow of urinary or fecal material—this keeps the wound clean and encourages wound healing. Reconstruction involves the complete removal of the ulcerated area and surrounding damaged tissue (excision), debriding the bone, and reducing the amount of bacteria in the area with vigorous flushing (lavage) with saline solution. The surgical wound is then drained for a period of days until it is clear that no infection is present and that healing has begun. Plastic surgery may follow to close the wound with a flap (skin from another part of the body), providing a new tissue surface over the bone. For surgery to succeed, infection must not be present. Complications can occur after reconstructive surgery; these include bleeding under the skin (hematoma), wound infection, and the recurrence of pressure sores. Infection in deep wounds can progress to life-threatening systemic infection. Amputation may be required when a wound will not heal or when reconstructive surgery is not an option for a particular patient.

Alternatives

Zinc and vitamins A, C, E, and B complex provide necessary nutrients for the skin and help it to repair injuries and stay healthy. Large doses of vitamins or minerals should not be used without a doctor’s approval.

A poultice made of equal parts of powdered slippery elm (Ulmus fulva), marsh mallow (Althaea officinalis), and echinacea blended with a small amount of hot water can relieve minor inflammation. An infection-fighting rinse of two drops of essential tea tree oil (Melaleuca) to every 8 oz (0.23 g) of water can also be administered. An herbal tea made from calendula (Calendula officinalis) is also an effective antiseptic and wound healing agent. Calendula cream can also be used.

Contrasting hot and cold compresses applied to the bedsore site can increase circulation to the area and help flush out waste products, speeding the healing process. The temperatures should be extreme (very hot and ice cold), yet tolerable to the skin. Hot compresses should be applied for three minutes, followed by 30 seconds of cold compress application, repeating the cycle three times. The cycle should always end with a cold compress.

Prevention

It is usually possible to prevent bedsores from developing or worsening. In 1989, the NPUAP set a goal that pressure sores be reduced by 50% by 2000. Because of the varying ways in which the number of cases were recorded during this timeframe, the NPUAP is finding it difficult to analyze accurate incident accounts. However even with the diversity of recording methods and the difficulties in comparing data, small group data indicates that progress has been made with the standardization of guidelines and care.

All patients recovering from illness or surgery or confined to a bed or wheelchair long-term should be inspected regularly; they should be bathed or should shower every day using warm water and mild soap; and patients should avoid cold or dry air. Bedridden patients who are either mentally unaware or physically unable to turn themselves, must be repositioned regularly by caregivers at least once every two hours while awake. People who use a wheelchair should be encouraged to shift their weight every 10 or 15 minutes, or be repositioned by caregivers at least once an hour. It is important to lift, rather than to drag, a person being repositioned. Bony parts of the body should not be massaged. Even slight friction can remove the weakened top layer of skin and damage blood vessels beneath it.

If the patient is bedridden, sensitive body parts can be protected by:

• sheepskin pads
• special cushions placed on top of a mattress
• a water-filled mattress
• a variable-pressure mattress with individually inflatable sections to redistribute pressure

For different overlay pads visit our online store anyOTC.com

Pillows or foam wedges can prevent a bedridden patient’s ankles from irritating each other, and pillows placed under the legs from mid-calf to ankle can raise the heels off the bed. Raising the head of the bed slightly and briefly can provide relief, but raising the head of the bed more than 30 degrees can cause the patient to slide, thereby causing damage to skin and tiny blood vessels.

A person who uses a wheelchair should be encouraged to sit up as straight as possible. Pillows behind the head and between the legs can help prevent bedsores, as can a special cushion placed on the chair seat. Donutshaped cushions should not be used because they restrict blood flow and cause tissues to swell.

Special support surfaces are manufactured and readily available for care in medical facilities or at home, including: air-filled mattresses and cushions, low-air loss beds, and air-fluidized beds. These devices give adequate support while reducing pressure on vulnerable skin. They have been shown to exert less pressure on the skin of compromised patients than do regular mattresses. Patients using these devices and beds must still be repositioned every two hours.