Tuesday, October 17, 2006

Settling Your Stomach

Although unpleasant subjects, stomach and intestinal disorders are important to know about.

The sudden onset of cramps, diarrhea, nausea, and vomitting are among the most frequent afflictions in otherwise healthy people. For some reason, however, many people with these symptoms stop listening to their bodies and make the worst mistake possible--namely, they immediately try to put stuff, food and medicine, back into their stomachs.

The impetus for this behavior may well be the plethora of oral (and occasionally rectal) remedies for intestinal maladies, a situation as old as medicine itself. In some cases, it's a fear of dehydration or starvation. In every case it's wrong.

In developed countries, the cause of most acute diarrhea and vomitting is infection of the stomach and intestines by one of two common viruses (Rotavirus and Norwalk agent). Occasionally, it can be caused by bacteria (Salmonella, Shigella, and Campylobacter speces), by parasites (Giardia and others), by food tainted by bacterial growth (Staphylococcal food poisoning, so-called "ptomaine poisoning"), or by conditions of the intestinal tract itself (including chemical gastritis, gall stones, inflammatory bowel disease, appendicitis). In less-developed countries, infections with Typhus and even cholera still occur.

But regardless of the cause, when your body starts expelling the contents of the intestinal tract, it means that your body doesn't "want" what's in there. It's usually best to let your body do its thing--the vomitting and diarrhea slow down or stop as soon as you empty out. To let your mind overrule your body, just because you saw a recent PeptoBismol or Dramamine commercial, is not wise.

An irritable stomach will throw up anything you put in it, and the more you throw up, the more irritated it becomes. An infected or inflamed intestine loses its ability to reabsorb water, and the more you feed it, the less time it has to recover.

There is only one logical step in this situation: DON'T EAT!!

That's all--don't eat, don't even drink.

Ninety percent of patients can cure themselves if they take that first initial step, and the rest will make their condition much easier to manage. If you wonder how long a person can go without eating or drinking, it's likely to be much longer than you think. Certainly no one with a moderate level of activity gets into trouble by fasting for four or five hours, not even children, not even babies.

Most adults can safely avoid eating and drinking for up to twelve hours on a regular basis (remember that Hakeem Alajuwon, a seven-foot-two, three-hundred-pound star basketball player for the Houston Rockets played a championship series while fasting twelve hours daily for the month of Ramadan). Diabetics who check their blood sugar may be surprised to find that they do not get seriously hypoglycemic even with medication "on board." Most of us carry a calorie reserve that will sustain us for two to three days, and enough water in our blood stream for a whole day.

The second and perhaps more crucial step in aiding the recovery of your stomach and intestines is to replenish your water and food loss slowly and with the simplest and easiest-to-digest substances possible. The most readily available substances of this type are what we call clear liquids, i.e.--foods that are already in solution. This includes clear carbonated beverages (e.g.--ginger ale or 7-Up), clear soup broth, Italian ice or Popsicles, and gelatin, Gatorade, as well as a number of commercial products designed specifically to replace lost fluids (Pedialyte, Kao-Lectrolyte, and others).

These all provide water, sugar for energy, and salts which keep the cells functioning properly. They are clear because these simple chemicals are in solution.

If you cannot see through the liquid or food, it contains other substances such as fat (as in milk) or complex carbohyrates (as in oatmeal) or fiber (as in pulpy juice), which your stomach, in this situation, is not ready to tolerate. You start with clear liquids and continue until the nausea or diarrhea stops--usually for twelve to twenty-four hours. Though they are not particularly satisfying, clear liquids can sustain a person for days if necessary.

The next step is to try low-fiber complex carbohydrates--starchy foods such as rice, potatoes, bread, usually for a full day.

After that you can eat any fruits and vegetables, as well as low-fat meats, but no dairy products for another five days; it will take that long for your intestinal tract to tolerate lactose, the main sugar in most milk products. Even people who digest lactose can have a temporary lactose intolerance after a viral infection or some other assault on the intestinal tract, and drinking milk is the worse thing one can do in that situation.

If you respond to an episode of gastroenteritis by wolfing a ham-and-cheese sandwich and washing it down with a glass of milk, you're doomed to five more days of misery. Just rest your gut for a few hours, gently replace the water and salts with clear liquids, start foods gradually and stay away from milk--and you're better in no time.

That was simply brilliant.

When I was a teenager and got "addicted" to jogging (I was only jogging 2 miles a day, but it felt SO good) I didn't know what to do when one of the Jewish fast days came up.
No food, no water.

I decided, heck, I don't really break into a sweat, I'll do it. I'll fast AND I'll jog the next day.

No trouble fasting whatsoever, plenty of energy for the run.
(And I wasn't overweight in the least, fyi, doc)
While this sounds like pretty sound advice, hydration is key. Often when people become ill with a foodborne illness they lose more fluids than they are able to take in, and have to go through re-hydration therapy at the ER.
Again, the keys on oral rehydration are (1) do it slo-o-o-owly and (2) don't use plain water, lest you end up low on sodium (dizziness) and potassium (muscle weakness). In the rare case when even a sip of clear liquids induces more vomitting, IV rehydration is indicated, but clinical studies have not shown that it is really more efficient than the oral method.
Speaking as a physician myself I think it is quite irresponsible of you to tell people "Don't eat, don't even drink".
When the body is combating any type of virus/bacteria/infection/etc... it is crucial for people to remain hydrated, especially if diarrhea and/or vomiting is present.
The key is not to fast all together, rather it is to eat smaller healthier portions, and to drink slow & often, while avoiding dairy products and any other food/drink which upsets your digestive system.
If a person is incapable of taking fluids orally they should always be started on a round of IV fluids immediately. Dehydration will not only make your symptoms worse, but it will also impair brain function and can result in serious complications.

I truly believe you should amend your article.

Thank you,
A "physician," Jo? Really? Any clinical experience treating gastroenteritis? If so, I am amazed at how you missed all the salient points of this piece:

-- 4, 5, or even 6 hours of fasting (from the onset of vomitting) in a previously healthy, normotensive individual (adult or child) will not cause dangerous dehydration. No one is advising folks to stay NPO forever, though for some, the thought of four hours awake without eating/drinking seems like mental torture. But the body can handle it fine, and the worst thing you can do for an irritated UGI system is throw some food and drink into it too early, thereby inducing more vomitting, as well as incurring the wrath of the surgical team, should you be dealing with an SBO or appe'.

-- Sure, you can treat every patient with acute gastroenteritis with IV fluids, but your outcomes (recovery time, co-morbidities) will be the same as with oral rehydration. Also be prepared for the vein scarring, line sepsis, and employing several adults to hold down a screaming, terrified child (who will never, EVER, forgive you!). In thirty years of clinical practice, I've resorted to IV rehydration for acute gastroenteritis less than six times (out of >4000 patient episodes), and I'm sure my experience is not different from any other doc in the "real world." No one died from following my simple protocol, and most didn't even have to see a doctor.

Using an irrational fear of potential dehydration to advise early feeding and IV fluids for common acute gastroenteritis symptoms is -- well, in your words -- so WRONG! I'm not making this up, BTW. Check your Cochrane data-base, WHO recommendations, or any other solid source of evidence-based medicine.
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