Fecal Incontinence - National Digestive Diseases Information ...


Fecal Incontinence - National Digestive Diseases Information ...

FecalIncontinenceNational Digestive Diseases Information ClearinghouseU.S. Departmentof Health andHuman ServicesNATIONALINSTITUTESOF HEALTHWhat is fecal incontinence?Fecal incontinence, also called a bowelcontrol problem, is the accidental passingof solid or liquid stool or mucus from therectum. Fecal incontinence includes theinability to hold a bowel movement untilreaching a toilet as well as passing stool intoone’s underwear without being aware of ithappening. Stool, also called feces, is solidwaste that is passed as a bowel movementand includes undigested food, bacteria,mucus, and dead cells. Mucus is a clearliquid that coats and protects tissues in thedigestive system.Fecal incontinence can be upsetting andembarrassing. Many people with fecalincontinence feel ashamed and try tohide the problem. However, people withfecal incontinence should not be afraid orembarrassed to talk with their health careprovider. Fecal incontinence is often causedby a medical problem and treatment isavailable.Who gets fecalincontinence?Nearly 18 million U.S. adults—about onein 12—have fecal incontinence. 1 People ofany age can have a bowel control problem,though fecal incontinence is more commonin older adults. Fecal incontinence is slightlymore common among women. Having anyof the following can increase the risk:• diarrhea, which is passing loose, waterystools three or more times a day• urgency, or the sensation of having verylittle time to get to the toilet for a bowelmovement• a disease or injury that damages the nervous system• poor overall health from multiple chronic, or long lasting, illnesses• a difficult childbirth with injuries to thepelvic floor—the muscles, ligaments,and tissues that support the uterus,vagina, bladder, and rectumWhat is the gastrointestinal(GI) tract?The GI tract is a series of hollow organsjoined in a long, twisting tube from themouth to the anus. The movement ofmuscles in the GI tract, along with therelease of hormones and enzymes, allowsfor the digestion of food. Organs that makeup the GI tract are the mouth, esophagus,stomach, small intestine, large intestine—which includes the appendix, cecum, colon,and rectum—and anus. The intestines aresometimes called the bowel. The last partof the GI tract—called the lower GI tract—consists of the large intestine and anus.1Whitehead WE, Borrud L, Goode PS, et al. Fecalincontinence in U.S. adults: epidemiology and riskfactors. Gastroenterology. 2009;137(2):512–517.

What causes fecalincontinence?Fecal incontinence has many causes,including• diarrhea• constipation• muscle damage or weakness• nerve damage• loss of stretch in the rectum• childbirth by vaginal delivery• hemorrhoids and rectal prolapse• rectocele• inactivityDiarrheaDiarrhea can cause fecal incontinence.Loose stools fill the rectum quickly andare more difficult to hold than solid stools.Diarrhea increases the chance of notreaching a bathroom in time.ConstipationConstipation can lead to large, hard stoolsthat stretch the rectum and cause the internalsphincter muscles to relax by reflex. Waterystool builds up behind the hard stool andmay leak out around the hard stool, leadingto fecal incontinence.The type of constipation that is most likelyto lead to fecal incontinence occurs whenpeople are unable to relax their externalsphincter and pelvic floor muscles whenstraining to have a bowel movement, oftenmistakenly squeezing these muscles insteadof relaxing them. This squeezing makes itdifficult to pass stool and may lead to a largeamount of stool in the rectum. This type ofconstipation, called dyssynergic defecationor disordered defecation, is a result offaulty learning. For example, children oradults who have pain when having a bowelmovement may unconsciously learn tosqueeze their muscles to delay the bowelmovement and avoid pain.Muscle Damage or WeaknessInjury to one or both of the sphinctermuscles can cause fecal incontinence. Ifthese muscles, called the external andinternal anal sphincter muscles, are damagedor weakened, they may not be strong enoughto keep the anus closed and prevent stoolfrom leaking.Trauma, childbirth injuries, cancer surgery,and hemorrhoid surgery are possible causesof injury to the sphincters. Hemorrhoids areswollen blood vessels in and around the anusand lower rectum.3 Fecal Incontinence

Nerve DamageThe anal sphincter muscles won’t open andclose properly if the nerves that controlthem are damaged. Likewise, if the nervesthat sense stool in the rectum are damaged,a person may not feel the urge to go to thebathroom. Both types of nerve damage canlead to fecal incontinence. Possible sourcesof nerve damage are childbirth; a long-termhabit of straining to pass stool; spinal cordinjury; and diseases, such as diabetes andmultiple sclerosis, that affect the nerves thatgo to the sphincter muscles and rectum.Brain injuries from stroke, head trauma,or certain diseases can also cause fecalincontinence.Loss of Stretch in the RectumNormally, the rectum stretches to holdstool until a person has a bowel movement.Rectal surgery, radiation treatment, andinflammatory bowel diseases—chronicdisorders that cause irritation and sores onthe lining of the digestive system—can causethe rectal walls to become stiff. The rectumthen can’t stretch as much to hold stool,increasing the risk of fecal incontinence.Childbirth by Vaginal DeliveryChildbirth sometimes causes injuries tomuscles and nerves in the pelvic floor. Therisk is greater if forceps are used to helpdeliver the baby or if an episiotomy—a cut inthe vaginal area to prevent the baby’s headfrom tearing the vagina during birth—isperformed. Fecal incontinence related tochildbirth can appear soon after delivery ormany years later.Hemorrhoids and RectalProlapseExternal hemorrhoids, which develop underthe skin around the anus, can preventthe anal sphincter muscles from closingcompletely. Rectal prolapse, a conditionthat causes the rectum to drop down throughthe anus, can also prevent the anal sphinctermuscles from closing well enough to preventleakage. Small amounts of mucus or liquidstool can then leak through the anus.RectoceleRectocele is a condition that causes therectum to protrude through the vagina.Rectocele can happen when the thin layerof muscles separating the rectum fromthe vagina becomes weak. For womenwith rectocele, straining to have a bowelmovement may be less effective becauserectocele reduces the amount of downwardforce through the anus. The result maybe retention of stool in the rectum. Moreresearch is needed to be sure rectoceleincreases the risk of fecal incontinence.InactivityPeople who are inactive, especially those whospend many hours a day sitting or lying down,have an increased risk of retaining a largeamount of stool in the rectum. Liquid stoolcan then leak around the more solid stool.Frail, older adults are most likely to developconstipation-related fecal incontinence forthis reason.4 Fecal Incontinence

special squirt bottle. A laxative is medicationthat loosens stool and increases bowelmovements. For this test, a thin tube with aballoon on its tip and pressure sensors belowthe balloon is inserted into the anus untilthe balloon is in the rectum and pressuresensors are located in the anal canal. Thetube is slowly pulled back through thesphincter muscle to measure muscle toneand contractions. No anesthesia is neededfor this test, which takes about 30 minutes.Anal ultrasound. Ultrasound uses adevice, called a transducer, that bouncessafe, painless sound waves off organs tocreate an image of their structure. Ananal ultrasound is specific to the anus andrectum. The procedure is performed ina health care provider’s office, outpatientcenter, or hospital by a specially trainedtechnician, and the images are interpretedby a radiologist—a doctor who specializes inmedical imaging. Anesthesia is not needed.The images can show the structure of theanal sphincter muscles.MRI. MRI machines use radio waves andmagnets to produce detailed pictures ofthe body’s internal organs and soft tissueswithout using x rays. The procedure isperformed in an outpatient center or hospitalby a specially trained technician, and theimages are interpreted by a radiologist.Anesthesia is not needed, though peoplewith a fear of confined spaces may be givenmedication to help them relax. An MRI mayinclude the injection of special dye, calledcontrast medium. With most MRI machines,the person lies on a table that slides intoa tunnel-shaped device that may be openended or closed at one end; some newermachines are designed to allow the personto lie in a more open space. MRIs can showproblems with the anal sphincter muscles.MRI is an alternative to anal ultrasoundthat may provide more detailed information,especially about the external anal sphincter.Defecography. This x ray of the area aroundthe anus and rectum shows how well theperson can hold and evacuate stool. Thetest also identifies structural changes in therectum and anus such as rectocele and rectalprolapse. To prepare for the test, the personuses two enemas and does not eat anything2 hours prior to the test. During the test,the health care provider fills the rectum witha soft paste that shows up on x rays and isthe same consistency as stool. The personsits on a toilet inside an x-ray machine. Theperson is first asked to pull in and squeezethe sphincter muscles to prevent leakage andthen to strain as if having a bowel movement.The radiologist studies the x rays to identifyproblems with the rectum, anus, and pelvicfloor muscles.6 Fecal Incontinence

Flexible sigmoidoscopy or colonoscopy.These tests are used to help diagnoseproblems causing fecal incontinence. Thetests are similar, but colonoscopy is usedto view the rectum and entire colon, whileflexible sigmoidoscopy is used to view justthe rectum and lower colon. These testsare performed at a hospital or outpatientcenter by a gastroenterologist. For bothtests, a health care provider will providewritten bowel prep instructions to follow athome. The person may be asked to follow aclear liquid diet for 1 to 3 days before eithertest. A laxative may be required the nightbefore the test. One or more enemas may berequired the night before and about 2 hoursbefore the test.In most cases, people will be given lightanesthesia, and possibly pain medication,to help them relax during flexiblesigmoidoscopy. Anesthesia is used forcolonoscopy. For either test, the person willlie on a table while the gastroenterologistinserts a flexible tube into the anus. A smallcamera on the tube sends a video image ofthe intestinal lining to a computer screen.The test can show problems in the lower GItract that may be causing the bowel controlproblem. The gastroenterologist may alsoperform a biopsy, a procedure that involvestaking a piece of tissue from the bowellining for examination with a microscope.The person will not feel the biopsy. Apathologist—a doctor who specializes indiagnosing diseases—examines the tissue in alab to confirm the diagnosis.Cramping or bloating may occur duringthe first hour after these tests. Driving isnot permitted for 24 hours after flexiblesigmoidoscopy or colonoscopy to allow theanesthesia time to wear off. Before theappointment, a person should make plans fora ride home. Full recovery is expected by thenext day and the person is able to go back toa normal diet.Anal EMG. Anal EMG checks the healthof the pelvic floor muscles and the nervesthat control the muscles. The healthcare provider inserts a very thin needleelectrode through the skin into the muscle.The electrode on the needle picks up theelectrical activity given off by the musclesand shows it as images on a monitor orsounds through a speaker. An alternativetype of anal EMG uses stainless steelplates attached to the sides of a plastic pluginstead of a needle. The plug is insertedinto the anal canal to measure the electricalactivity of the external anal sphincter andother pelvic floor muscles. The averageamount of electrical activity when the personrelaxes quietly, squeezes to prevent a bowelmovement, and strains to have a bowelmovement shows whether there is damage tothe nerves that control the external sphincterand pelvic floor muscles.7 Fecal Incontinence

How is fecal incontinencetreated?Treatment for fecal incontinence may includeone or more of the following:• eating, diet, and nutrition• medications• bowel training• pelvic floor exercises and biofeedback• surgery• electrical stimulationEating, Diet, and NutritionDietary changes that may improve fecalincontinence include• Eating the right amount of fiber.Fiber can help with diarrhea andconstipation. Fiber is found in fruits,vegetables, whole grains, and beans.Fiber supplements sold in a pharmacyor in a health food store are anothercommon source of fiber to treatfecal incontinence. The Academy ofNutrition and Dietetics recommendsconsuming 20 to 35 grams of fiber a dayfor adults and “age plus five” gramsfor children. A 7-year-old child, forexample, should get “7 plus five,” or12, grams of fiber a day. Americanadults consume only 15 grams a day onaverage. 2 Fiber should be added to thediet slowly to avoid bloating.• Getting plenty to drink. Drinking eight8-ounce glasses of liquid a day may helpprevent constipation. Water is a goodchoice. Drinks with caffeine, alcohol,milk, or carbonation should be avoidedif they trigger diarrhea.Keeping a Food DiaryA food diary can help identify foods thatcause diarrhea and increase the risk offecal incontinence. A food diary shouldlist foods eaten, portion size, and whenfecal incontinence occurs. After a fewdays, the diary may show a link betweencertain foods and fecal incontinence.Eating less of foods linked to fecalincontinence may improve symptoms.A food diary can also be helpful to ahealth care provider treating a personwith fecal incontinence.Common foods and drinks linked tofecal incontinence include• dairy products such as milk, cheese,and ice cream• drinks and foods containing caffeine• cured or smoked meat such as sausage, ham, and turkey• spicy foods• alcoholic beverages• fruits such as apples, peaches, andpears• fatty and greasy foods• sweeteners in diet drinks andsugarless gum and candy, includingsorbitol, xylitol, mannitol, andfructose2Slavin JL. Position of the American Dietetic Association:health implications of dietary fiber. Journal of theAmerican Dietetic Association. 2008;108(31):1716–1731.8 Fecal Incontinence

Examples of Foods That Have FiberBeans, cereals, and breadsFiber1/2 cup of beans (navy, pinto, 6.2–9.6 gramskidney, etc.), cooked1/2 cup of shredded wheat, 2.7–3.8 gramsready-to-eat cereal1/3 cup of 100% bran, 9.1 gramsready-to-eat cereal1 small oat bran muffin 3.0 grams1 whole-wheat English muffin 4.4 gramsFruits1 small apple, with skin 3.6 grams1 medium pear, with skin 5.5 grams1/2 cup of raspberries 4.0 grams1/2 cup of stewed prunes 3.8 gramsVegetables1/2 cup of winter squash, cooked 2.9 grams1 medium sweet potato, baked in skin 3.8 grams1/2 cup of green peas, cooked 3.5–4.4 grams1 small potato, baked, with skin 3.0 grams1/2 cup of mixed vegetables, cooked 4.0 grams1/2 cup of broccoli, cooked 2.6–2.8 grams1/2 cup of greens (spinach, collards, 2.5–3.5 gramsturnip greens), cookedSource: U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines forAmericans, 2010.9 Fecal Incontinence

MedicationsIf diarrhea is causing fecal incontinence,medication may help. Health careproviders sometimes recommend using bulklaxatives, such as Citrucel and Metamucil,to develop more solid stools that are easierto control. Antidiarrheal medications suchas loperamide or diphenoxylate may berecommended to slow down the bowels andhelp control the problem.Bowel TrainingDeveloping a regular bowel movementpattern can improve fecal incontinence,especially fecal incontinence due toconstipation. Bowel training involves tryingto have bowel movements at specific timesof the day, such as after every meal. Overtime, the body becomes used to a regularbowel movement pattern, thus reducingconstipation and related fecal incontinence.Persistence is key to successful boweltraining. Achieving a regular bowel controlpattern can take weeks to months.Pelvic Floor Exercises andBiofeedbackExercises that strengthen the pelvic floormuscles may improve bowel control. Pelvicfloor exercises involve squeezing and relaxingpelvic floor muscles 50 to 100 times a day. Ahealth care provider can help with propertechnique. Biofeedback therapy may alsohelp a person perform the exercises properly.This therapy also improves a person’sawareness of sensations in the rectum,teaching how to coordinate squeezing of theexternal sphincter muscle with the sensationof rectal filling. Biofeedback training usesspecial sensors to measure bodily functions.Sensors include pressure or EMG sensorsin the anus, pressure sensors in the rectum,and a balloon in the rectum to producegraded sensations of rectal fullness. Themeasurements are displayed on a videoscreen as sounds or line graphs. The healthcare provider uses the information to helpthe person modify or change abnormalfunction. The person practices the exercisesat home. Success with pelvic floor exercisesdepends on the cause of fecal incontinence,its severity, and the person’s motivation andability to follow the health care provider’srecommendations.SurgerySurgery may be an option for fecalincontinence that fails to improve with othertreatments or for fecal incontinence causedby pelvic floor or anal sphincter muscleinjuries.• Sphincteroplasty, the most commonfecal incontinence surgery, reconnectsthe separated ends of a sphinctermuscle torn by childbirth or anotherinjury. Sphincteroplasty is performed ata hospital by a colorectal, gynecological,or general surgeon.• Artificial anal sphincter involvesplacing an inflatable cuff around theanus and implanting a small pumpbeneath the skin that the personactivates to inflate or deflate the cuff.This surgery is much less common andis performed at a hospital by a speciallytrained colorectal surgeon.10 Fecal Incontinence

• Nonabsorbable bulking agents can beinjected into the wall of the anus tobulk up the tissue around the anus. Thebulkier tissues make the opening of theanus narrower so the sphincters areable to close better. The procedure isperformed in a health care provider’soffice; anesthesia is not needed. Theperson can return to normal physicalactivities 1 week after the procedure.• Bowel diversion is an operation thatreroutes the normal movement of stoolout of the body when part of the bowelis removed. The operation diverts thelower part of the small intestine orcolon to an opening in the wall of theabdomen—the area between the chestand hips. An external pouch is attachedto the opening to collect stool. Theprocedure is performed by a surgeon ina hospital and anesthesia is used. Moreinformation about these procedurescan be found in the National DigestiveDiseases Information Clearinghousefact sheet Bowel Diversion atwww.digestive.niddk.nih.gov.Electrical StimulationElectrical stimulation, also called sacralnerve stimulation or neuromodulation,involves placing electrodes in the sacralnerves to the anus and rectum andcontinuously stimulating the nerves withelectrical pulses. The sacral nerves connectto the part of the spine in the hip area.A battery-operated stimulator is placedbeneath the skin. Based on the person’sresponse, the health care provider canadjust the amount of stimulation so it worksbest for that person. The person can turnthe stimulator on or off at any time. Theprocedure is performed in an outpatientcenter using local anesthesia.What are some practicaltips for coping with fecalincontinence?Fecal incontinence can causeembarrassment, fear, and loneliness. Takingsteps to cope is important. The followingtips can help:• carrying a bag with cleanup supplies anda change of clothes when leaving thehouse.• finding public restrooms before one isneeded.• using the toilet before leaving home.• wearing disposable underwear or absorbent pads inserted in the underwear. • using fecal deodorants—pills thatreduce the smell of stool and gas.Although fecal deodorants are availableover the counter, a health care providercan help people find them.Eating tends to trigger contractions of thelarge intestine that push stool toward therectum and also cause the rectum to contractfor 30 to 60 minutes. Both these eventsincrease the likelihood that a person willpass gas and have a bowel movement soonafter eating. This activity may increase ifthe person is anxious. People with fecalincontinence may want to avoid eating inrestaurants or at social gatherings, or theymay want to take antidiarrheal medicationsbefore eating in these situations.11 Fecal Incontinence

What if a child has fecalincontinence?A child with fecal incontinence who istoilet trained should see a health careprovider, who can determine the cause andrecommend treatment. Fecal incontinencecan occur in children because of a birthdefect or disease, but in most cases it occursbecause of constipation.Children often develop constipation asa result of stool withholding. They maywithhold stool because they are stressedabout toilet training, embarrassed to use apublic bathroom, do not want to interruptplaytime, or are fearful of having a painful orunpleasant bowel movement.As in adults, constipation in children cancause large, hard stools that get stuck in therectum. Watery stool builds up behind thehard stool and may unexpectedly leak out,soiling a child’s underwear. Parents oftenmistake this soiling as a sign of diarrhea.Points to Remember• Fecal incontinence, also called a bowelcontrol problem, is the accidentalpassing of solid or liquid stool or mucusfrom the rectum. Fecal incontinenceincludes the inability to hold a bowelmovement until reaching a toilet as wellas passing stool into one’s underwearwithout being aware of it happening.• Nearly 18 million U.S. adults—aboutone in 12—have fecal incontinence.People with fecal incontinence shouldnot be afraid or embarrassed to talkwith their health care provider.• Fecal incontinence has many causes,including– diarrhea– constipation– muscle damage or weakness– nerve damage– loss of stretch in the rectum– childbirth by vaginal delivery– hemorrhoids and rectal prolapse– rectocele– inactivity• Health care providers diagnose fecalincontinence based on a person’smedical history, physical exam, andmedical test results.• Treatment for fecal incontinence mayinclude one or more of the following:– eating, diet, and nutrition– medications– bowel training– pelvic floor exercises and biofeedback– surgery– electrical stimulation• A food diary can help identify foodsthat cause fecal incontinence.• Fecal incontinence can occur in childrenbecause of a birth defect or disease,but in most cases it occurs because ofconstipation.13 Fecal Incontinence

Hope through ResearchThe National Institute of Diabetes andDigestive and Kidney Diseases (NIDDK)and other components of the NationalInstitutes of Health (NIH) conduct andsupport research into many kinds of digestivedisorders, including fecal incontinence. TheBehavioral Therapy of Obstetric SphincterTears (BOOST), funded under NIH clinicaltrial number NCT01166399, surveys womenwho suffered a tear of the anal sphinctersduring childbirth to determine the incidenceof fecal incontinence in this population.The NIDDK is sponsoring a study ofbiofeedback for fecal incontinence,funded under NIH clinical trial numberNCT00124904. The aims of the study areto compare biofeedback with alternativetherapies, identify which patients are mostlikely to benefit, and assess the effect oftreatment on quality of life.Adaptive Behaviors among Women withBowel Incontinence: The ABBI Trial,funded under NIH clinical trial numberNCT00729144, focuses on the validationof the Adaptation Index instrument as ameasurement of adaptive behaviors usedto reduce symptoms of fecal incontinenceamong women. The Adaptation Index wasdeveloped with input from investigatorsof the Pelvic Floor Disorders Networkand refined through focus groups and isbeing validated in women with urinaryincontinence and pelvic organ prolapse.Clinical trials are research studies involvingpeople. Clinical trials look at safe andeffective new ways to prevent, detect, ortreat disease. Researchers also use clinicaltrials to look at other aspects of care, suchas improving the quality of life for peoplewith chronic illnesses. To learn more aboutclinical trials, why they matter, and how toparticipate, visit the NIH Clinical ResearchTrials and You website at www.nih.gov/health/clinicaltrials. For information about currentstudies, visit www.ClinicalTrials.gov.For More InformationAmerican Academy of Family PhysiciansP.O. Box 11210Shawnee Mission, KS 66207–1210Phone: 1–800–274–2237 or 913–906–6000Fax: 913–906–6075Email: fp@aafp.orgInternet: www.aafp.orgAmerican College of Gastroenterology6400 Goldsboro Road, Suite 200Bethesda, MD 20817Phone: 301–263–9000Email: info@acg.gi.orgInternet: www.acg.gi.orgAmerican Gastroenterological Association4930 Del Ray AvenueBethesda, MD 20814Phone: 301–654–2055Fax: 301–654–5920Email: member@gastro.orgInternet: www.gastro.orgAmerican Neurogastroenterology andMotility Society45685 Harmony LaneBelleville, MI 48111Phone: 734–699–1130Fax: 734–699–1136Email: admin@motilitysociety.orgInternet: www.motilitysociety.org14 Fecal Incontinence

International Foundation for FunctionalGastrointestinal DisordersP.O. Box 170864Milwaukee, WI 53217–8076Phone: 1–888–964–2001 or 414–964–1799Fax: 414–964–7176Email: iffgd@iffgd.orgInternet: www.iffgd.orgPelvic Floor Disorders NetworkData Coordinating Center6110 Executive Boulevard, Suite 420Rockville, MD 20852Phone: 301–230–4645Fax: 301–230–4647Internet: http://pfdn.rti.orgThe Simon Foundation for ContinenceP.O. Box 815Wilmette, IL 60091Phone: 1–800–23–SIMON (1–800–237–4666)or 847–864–3913Fax: 847–864–9758Internet: www.simonfoundation.orgVoices for PFDAmerican Urogynecologic SocietyFoundation2025 M Street NW, Suite 800Washington, D.C. 20036Phone: 202–367–1167Fax: 202–367–2167Email: info@augs.orgInternet: www.voicesforpfd.orgAcknowledgmentsPublications produced by the Clearinghouseare carefully reviewed by both NIDDKscientists and outside experts. Thispublication was originally reviewed byArnold Wald, M.D., University of PittsburghMedical Center; Paul Hyman, M.D.,University of Kansas Medical Center; andDiane Darrell, A.P.R.N., B.C., ResearchCollege of Nursing, Kansas City, MO.William E. Whitehead, Ph.D., University ofNorth Carolina Center for Functional GI andMotility Disorders, reviewed the updatedversion of the publication.The Bowel ControlAwareness CampaignThe National Institute of Diabetes andDigestive and Kidney Diseases (NIDDK)Bowel Control Awareness Campaignprovides current, science-based informationabout the symptoms, diagnosis, andtreatment of bowel control problems,also known as fecal incontinence. TheAwareness Campaign is an initiative of theNational Digestive Diseases InformationClearinghouse, a service of the NIDDK.Download this publication and learnmore about the Awareness Campaign atwww.bowelcontrol.nih.gov.15 Fecal Incontinence

You may also find additional information about thistopic by visiting MedlinePlus at www.medlineplus.gov.This publication may contain information aboutmedications. When prepared, this publicationincluded the most current information available.For updates or for questions about any medications,contact the U.S. Food and Drug Administration tollfreeat 1–888–INFO–FDA (1–888–463–6332) or visitwww.fda.gov. Consult your health care provider formore information.The U.S. Government does not endorse or favor anyspecific commercial product or company. Trade,proprietary, or company names appearing in thisdocument are used only because they are considerednecessary in the context of the information provided.If a product is not mentioned, the omission does notmean or imply that the product is unsatisfactory.National Digestive DiseasesInformation Clearinghouse2 Information WayBethesda, MD 20892–3570Phone: 1–800–891–5389TTY: 1–866–569–1162Fax: 703–738–4929Email: nddic@info.niddk.nih.govInternet: www.digestive.niddk.nih.govThe National Digestive Diseases InformationClearinghouse (NDDIC) is a service of theNational Institute of Diabetes and Digestiveand Kidney Diseases (NIDDK). TheNIDDK is part of the National Institutes ofHealth of the U.S. Department of Healthand Human Services. Established in 1980,the Clearinghouse provides informationabout digestive diseases to people withdigestive disorders and to their families,health care professionals, and the public.The NDDIC answers inquiries, develops anddistributes publications, and works closelywith professional and patient organizationsand Government agencies to coordinateresources about digestive diseases.This publication is not copyrighted. The Clearinghouseencourages users of this publication to duplicate anddistribute as many copies as desired.This publication is available atwww.digestive.niddk.nih.gov.U.S. DEPARTMENT OF HEALTHAND HUMAN SERVICESNational Institutes of HealthNIH...Turning Discovery Into Health ®NIH Publication No. 13–4866December 2012The NIDDK prints on recycled paper with bio-based ink.

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