This transcript has been edited for clarity.
Hello. I’m Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to GI Common Concerns and my series on gastrointestinal (GI) pearls.
This series is a built upon a conversation I had with Dr Alvin Zfass, from Virginia Commonwealth University, at a regional event sponsored by the American College of Gastroenterology. As we shared a stage that day, we calculated that between us we had approximately 118 years of experience. We discussed many of the lessons we’ve learned not in class nor in books, but from that collective experience. Those lessons are distilled into the GI pearls I’d like to impart to my colleagues.
The first two discussions in this series offered GI pearls related to esophageal conditions and gastric/abdominal symptoms.
Today, I’d like to move a little bit south anatomically and offer some pearls related to small-bowel and perianal conditions, which will hopefully be applicable to your practice.
Celiac Disease
In recent years, a massive industry has emerged to provide gluten-free products to patients with celiac disease and others.
Patients routinely ask me which personal care products they can and can’t use, such as soaps and shampoos. I help them understand that the gluten molecule is too big to be absorbed through the skin. The exception is when exposure occurs at the lips and buccal areas of the oral cavity, where absorption can take place, or in the oropharynx. When gluten is absorbed and/or swallowed in this manner, it induces the upregulation of zonulin, which then decreases intestinal integrity. Therefore, although gluten avoidance is obviously important in these patients, it’s not important to avoid products such as shampoos and soaps, so long as they are not exposed in the oropharyngeal area.
Certainly, it is possible to accidentally inhale gluten, for example if someone worked in a bakery. Inhalation of gluten doesn’t necessarily mean that it gets absorbed by the lungs, but it does get exposed to the nasopharynx and the oropharynx, which can lead to inadvertent swallowing and resulting introduction to the GI tract and upregulation of zonulin.
Dental hygiene products are another important consideration. This is because the risk for dental deterioration is higher in celiac disease, because it is known to cause dental attrition and defects of the enamel. Such effects are more common in those who develop celiac disease in childhood rather than as adults. For this reason, it’s important for patients to consider avoiding gluten exposure when selecting mouthwash, floss, and other dental products.
Patients should consider gluten exposures at restaurants. Sometimes, patients will tell me that they’re going to a “gluten-free restaurant.” That’s great, if the restaurants are truly offering gluten-free options. A 2019 study from researchers at Columbia University looked at gluten exposure at restaurants offering supposedly gluten-free food options. Using a mobile detection device, they found that gluten was present in approximately one third of gluten-free–labeled foods. This was particularly true of pasta and pizza, in which gluten was detected in over 50% of samples. Restaurants really have to be dedicated to monitoring and eliminating gluten exposure, because of the risk for cross-contamination in pots, pans, utensils, etc.
The final exposure to advise your patients about is topical exposure. Although, as noted, gluten doesn’t get absorbed through the skin, some patients will tell me that they experience an allergic reaction when something like a wheat product touches their skin. (Note: Dermatitis herpetiformis is a skin condition caused by ingestion of gluten itself and is not what we’re discussing here.) Patients may have a true wheat allergy. That may not be related to celiac disease, but just something they seek to avoid. I recommend these patients see an allergist if that’s an ongoing issue.
Constipation and Obstipation
It’s very important to delineate constipation from obstipation. The latter condition relates to pelvic floor dysfunction.
In differentiating these two, I always begin with a digital rectal exam of both the internal and external sphincters, during which I have the patient squeeze. I apply the digital rectal exam further into the area of the puborectalis and have the patient bear down, and then I try to push down, which eventually should result in relaxation of the puborectalis. Following that, I change the angulation as it relates to exposure to the rectum and the anal canal, which is important to detect if they have pelvic floor dysfunction.
This exam is comparable to an anorectal motility study, which is something you may or may not have performed. A digital rectal exam is something of a lost art, and it’s important to be aware of how to employ it when necessary.
When it comes to obstipation, one of the things I’ve found extremely helpful is what I call “toilet seat maneuvers.”
I tell my patients that if they have a calf spasm or another common muscle spasm, it helps to push on it to relax the muscle. In patients with obstipation, the internal anal sphincter or the puborectalis may not be relaxing. By changing the angulation on the toilet seat, it may facilitate relaxation or the angle of delivery to the rectum.
During these maneuvers, I advise them to lean up (particularly on the left side), reach back, and pull on the anal area, sometimes wiping with a tissue paper or using a tissue paper to insert a little bit of the finger. At this point, I advise them to take deep diaphragmatic breaths and then relax and hold for 30-60 seconds to see what they can stimulate. Sometimes it helps if they maneuver to the right side or backward and forward; it is necessarily a very slow rocking motion but simply more about giving the process time to work.
There are commercial products sold for feet placement while on the toilet, but I don’t think they are necessary to achieve the recommended angulation and elevation.
These maneuvers are quite easy and are something I often recommend to my patients.
For the treatment of constipation, I have a simple dietary recommendation: a combination of the high-fiber cereal All-Bran and yogurt. I can’t tell you how many thousands of patients I’ve put on this. The fiber component of All-Bran is 12-16 g, depending on whether it comes in the flake or pellet form. It’s very simple to prepare. I have patients mix it with yogurt, perhaps in combination with fresh fruit. I have them do this every day. I find it extraordinarily simple, easy, and helpful for constipation.
Another pearl was taught to me by one of the all-time greats in GI medicine, Dr Marvin Schuster, from Johns Hopkins University School of Medicine. A long time ago, he told me about the use of Smooth Move (senna) tea. It’s easy to find this on the shelves on health food stores. It has a stimulant effect on the colon and offers another simple and easy intervention to potentially recommend for your patients who are constipated.
Fecal Incontinence and Fecal Leakage
What do we do for fecal incontinence?
We need to first make sure it’s not a fecal impaction, which may lead to overflow incontinence. You don’t want to treat patients for diarrhea when they have a perception of fecal incontinence, while the source is actually a fecal impaction. In patients who have risk factors for fecal impaction, perform a rectal exam before you prescribe treatment with an antidiarrheal effect.
There are data supporting the efficacy of a low-inflammatory diet, as well as data on psyllium, for this indication. With a low-inflammatory diet, patients are asked to avoid food and drinks such as processed meat, red meat, high-fat foods, refined grain products, sugary beverages, high-fructose corn syrup, and even certain vegetables with inflammatory effects. Conversely, helpful vegetables to include in low-inflammatory diets are green leafy vegetables and yellow and orange vegetables.
I also tell my patients: Build your meal rather than buy your meal. This is because processed foods tend to have undergone much more enrichment, which has inflammatory side effects.
Dr Arnold Wald, a dear friend and long-standing colleague, taught me another pearl many years ago, which is to use a cotton plug for fecal incontinence. Fecal plugs are commercially sold, but they don’t seem to be tolerated by patients or even work very well. But, a cotton plug inserted in the anal canal may be helpful when combined with a panty liner or a protective flap type of product. This may be something you could use in your armamentarium as well.
When treating these patients, don’t overlook the potential that what they describe as incontinence may be fecal leakage.
In my practice, I’ve found that a lot of these patients have hemorrhoids that will prolapse back and forth. You can envision this as a process whereby the hemorrhoids prolapse down and change the integrity of the anal sphincter. Therefore, you may have liquid stored as it is normally, waiting in the rectum for evacuation when a critical distention pressure is reached. However, it may instead leak out down the hemorrhoidal prolapse. In such cases, treatment of the hemorrhoids may remedy the underlying fecal leakage. The treatments for hemorrhoids are relatively simple.
Hemorrhoids are something I always ask about in my patients reporting fecal leakage.
Even with colonoscopy, if hemorrhoids were identified, I ask patients if they also have incontinence, as well as about fecal seepage and soiling on the underwear. Those are things that may not be brought up in a normal discussion of hemorrhoids.
Rectal Fissures
The last topic I want to discuss is the treatment and diagnosis of rectal fissures.
Fissures are possible in the axis of the anal sphincter, anterior or posterior. This is not related to a systemic disease or inflammatory bowel disease. However, when it’s observed off of that axis, you do want to consider conditions such as Crohn’s disease.
Anal pain on defecation is a very classic symptom of rectal fissures. Patients report a sensation almost as if broken glass is travelling through the anal canal.
The treatment for these fissures is usually rectal nitroglycerin, although you can use calcium-channel blockers in composite topical exposures. I have my nitroglycerin ointment created in a 0.13% formulation from a compounding pharmacy. It’s very expensive to use commercially available nitroglycerin, whereas a compounding pharmacy can easily do this at a much-reduced cost.
With nitroglycerin ointment, the pearl is to make sure that your patients apply this treatment appropriately.
The length of the anal sphincter is about the size of your first digit from the fingertip to the proximal interphalangeal (PIP) joint. I advise patients to put a pea-sized dollop on the gloved finger and insert that finger up to that first PIP joint. Just dabbing it on the outside will not spread the treatment to the full length of the sphincter, which is what is needed. Instead, they have to insert that finger up to the PIP and move it around a little, back and forth.
To make it work effectively, I ask them to apply it three times a day for approximately 2 weeks.
There are other treatments if nitroglycerin is not providing the help they need. For example, if the patient is allergic or has problems with nitroglycerin, I’ve used topical diltiazem and nifedipine, which is a calcium-channel blocker that has had some efficacy. However, nitroglycerin is the first option.
In conclusion, these pearls on small-bowel and perianal conditions are the things that they don’t teach in class, but hopefully they are ones that you can use in your practice.
I look forward to our next discussion, in which I will offer one last set of GI pearls.
I’m Dr David Johnson. Thanks for listening.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.