Mucus in stool crohn’s

Anatomy of a Crohn’s Flare

How Long Does a Crohn’s Flare Last?

The length and frequency of a Crohn’s flare is highly individual, says David S. Lee, MD, a gastroenterologist at NewYork–Presbyterian. In general, a flare can last anywhere from a few days to several months. It’s important to work with your doctor on the best treatment. “If a flare isn’t treated, it can cause permanent damage and scarring, so proper management of Crohn’s disease is important,” he says.

How Can You Prepare for a Crohn’s Flare?

Effective medications help with the management of Crohn’s disease. “These medications treat inflammation and prevent complications,” Dr. Lee says.

In addition to following the medication schedule outlined by your doctor, consider this Crohn’s advice to help prevent a flare and alleviate symptoms if one does strike.

  • Relax. Some small studies have shown that relaxation exercises and rest can sometimes help alleviate Crohn’s symptoms, Lee says. Try yoga, tai chi, or meditation. A study published in April 2015 in PLoS One found meditation may also suppress inflammation and lessen the symptoms of both irritable bowel syndrome (IBS) and irritable bowel disease (IBD), both of which can be triggered by stress. In the study, 19 people with IBS and 29 with IBD signed on for a nine-month program of 15 to 20 minutes each day that included both meditation and yoga. Blood samples taken at the completion of the study demonstrated changes in genetic pathways related to both IBS and IBD patients. Researchers noted that an inflammation-related gene, NF-kB, was suppressed by the relaxation methods. Therefore, the researchers concluded that stress and inflammation can be offset by relaxation techniques.
  • Be prepared. Crohn’s flares can strike at any time — at home, in the car, at the office, and when you’re on a deadline at work or need to make a meeting at your child’s school. “If you have Crohn’s disease, you should be prepared at all times by noting where the restrooms are and keeping a spare set of clothes in the car or nearby, just in case,” Dr. Rood says.
  • Ease pain with the right over-the-counter medication. “If you have pain related to Crohn’s disease, take Tylenol only, since ibuprofen and NSAIDs (nonsteroidal anti-inflammatory drugs) can worsen inflammation and symptoms,” Lee says.

Above all, befriend your gastroenterologist. “Management of Crohn’s disease with medications and close follow-up with a gastroenterologist can help prevent Crohn’s flares in the first place,” Lee says.

What Are Signs You May Need a Doctor’s Attention?

There are three main complications related to Crohn’s disease: stricturing (the narrowing of the intestines), abscess (an infectious collection), and fistulas (connections between the intestines and adjacent organs, intestines, and skin). Each complication can cause certain symptoms.

  • Stricturing can lead to crampy abdominal pain, nausea, bloating, and vomiting. A study published in January 2015 in Intestinal Research noted that 25 percent of Crohn’s patients have had at least one small bowel stricture and 10 percent have had at least one colonic stricture that led to serious complications. Researchers note that a diagnosis under age 40, perianal disease (inflammation near the anus), and the need for steroids during the first flare are the most prevalent clinical parameters for predicting intestinal stricture. A history of smoking is another risk factor for Crohn’s complications and the onset of a stricture after diagnosis.
  • Abscess can give you a high, spiking fever, abdominal pain, and, depending on the location, possibly lower-back and leg pain.
  • With fistulas, feces and air come out of abnormal places, such as the skin, vagina, or urinary tract.

Any of these symptoms merit a phone call or visit to your doctor.

Are you doing everything you can to manage your Crohn’s? Find out with our interactive checkup.

The better you’re prepared for a flare and how it will affect your routine, the better you’ll be at dealing with it when it occurs.

Crohn’s Disease

Medically reviewed by Drugs.com. Last updated on Jan 25, 2019.

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What Is It?

Crohn’s disease is an inflammatory bowel disease in which inflammation injures the intestines. It is a long-term (chronic) condition. Crohn’s disease typically begins between ages 15 and 40.

No one knows for sure what triggers the initial intestinal inflammation at the start of Crohn’s disease. A viral or bacterial infection may start the process by activating the immune system in the intestine. However, the immune system attack is not turned off: it stays active and creates inflammation even after the infection goes away.

Certain genes passed on from parent to child increase the risk of developing Crohn’s disease, if the right trigger occurs.

Once Crohn’s disease begins, it can cause lifelong symptoms that come and go. The inner lining of the intestine thickens, and can wear away. The deeper layers of the intestine also become inflamed. This creates ulcers, cracks and fissures. Inflammation can allow an abscess (a pocket of pus) to develop.

A common complication of Crohn’s disease is called a fistula. A fistula is an abnormal connection between organs in the digestive tract, usually between one part of the intestine and another. A fistula can be created after inflammation becomes severe.

The section of the small intestine called the ileum is especially prone to damage from Crohn’s disease. The ileum is located in the right lower abdomen. However, ulcers and inflammation can occur in all areas of the digestive tract, from the mouth to the rectum.

A few other parts of the body, such as the eyes and joints, also can be affected by Crohn’s disease.

Symptoms

Some people with Crohn’s disease have only occasional cramps, or diarrhea. Their symptoms are so mild they do not seek medical attention.

However, most people with Crohn’s disease have more bothersome symptoms. They may experience long stretches of time with no symptoms. But these are interrupted by flare-ups of symptoms.

When Crohn’s disease first begins, or during a flare-up, you might experience:

  • Abdominal pain, usually at or below the navel. It is typically worse after meals.

  • Diarrhea that may contain blood

  • Sores around the anus

  • Drainage of pus or mucus from the anus or anal area

  • Pain when you have a bowel movement

  • Mouth sores

  • Loss of appetite

  • Joint pains or back pain

  • Pain or vision changes in one or both eyes

  • Weight loss despite eating a normal-calorie diet

  • Fever

  • Weakness or fatigue

  • Stunted growth and delayed puberty in children

Diagnosis

There is no definitive diagnostic test for Crohn’s disease. If you have Crohn’s disease, your symptoms and the results of various tests will fit a pattern over time. This pattern will be best explained by Crohn’s disease.

It may require months for your doctor to diagnose Crohn’s disease with certainty.

Your doctor will look for evidence of intestinal inflammation. He or she will try to distinguish it from other causes of intestinal problems such as infection or ulcerative colitis. Ulcerative colitis is another disease that, like Crohn’s diseases, also causes intestinal inflammation.

Test abnormalities that are often, but not always, found in people with Crohn’s disease include:

  • Blood tests. Show a high white blood cell count or other signs of inflammation. Crohn’s disease can interfere with the absorption of vitamin B12, which can lead to anemia, a reduced number of red blood cells: anemia and low levels of vitamin B12 can show up on blood tests.

  • Autoantibody tests. Reveal antibodies in the blood of people with Crohn’s disease. They may help distinguish between inflammation caused by Crohn’s disease versus ulcerative colitis.

  • Stool tests. Also called feces or bowel movement tests.

    • Detect small amounts of blood from irritated intestines.

    • Make sure that there is no infection causing the symptoms.

  • Upper gastrointestinal (GI) series. A test in which x-ray pictures are taken of your abdomen after you drink a barium solution that shows up on X-rays. As the liquid trickles down, it traces the outline of your intestines on the X-ray. An upper GI series can reveal places in the small intestine that are narrowed. It also can highlight ulcers and fistulas. These abnormalities are found more often in Crohn’s disease than in ulcerative colitis, or other conditions that cause symptoms similar to Crohn’s disease symptom.

  • Flexible sigmoidoscopy or colonoscopy tests. These tests use a small tube with an attached camera and light. The tube is inserted into your rectum, allowing your doctor to view the insides of your large intestine. These tests are usually done when Crohn’s disease is suspected.

  • MR Enterography. A relatively new test that provides pictures of the entire intestine without radiation. It uses magnetic resonance imaging to show areas of Crohn’s involvement.

  • Wireless capsule endoscopy. The test involves swallowing a pill-sized object that is a tiny little video camera. It sends pictures of your small intestine wirelessly. Unlike x-ray studies such as the upper GI series, no x-ray radiation is involved.

  • Biopsy. The removal of a small sample of tissue from the lining of the intestine. The material is examined in a laboratory for signs of inflammation. A biopsy is most helpful to confirm Crohn’s disease and to exclude other conditions.

Expected Duration

Crohn’s disease is a lifelong condition. But it is not continuously active.

Following a flare-up, symptoms can stay with you for weeks or months. Often these flare-ups are separated by months or years of good health without any symptoms.

Prevention

There is no way to prevent Crohn’s disease.

But you can keep the condition from taking a heavy toll on your body. Maintain a well-balanced, nutritious diet to store up vitamins and nutrients between episodes or flare-ups. By doing so, you can decrease complications from poor nutrition, such as weight loss or anemia.

Also, do not smoke. Along with many other harmful health effects, smoking probably makes flare-ups of Crohn’s disease happen more frequently.

Crohn’s disease can increase your risk of getting colon cancer. Have your colon checked regularly for early cancerous or precancerous changes. If you have had Crohn’s disease affecting the colon or rectum for eight years or more, start getting regular colonoscopies. Have a colonoscopy exam every one to two years once you start regular testing.

Treatment

Medications are very effective at improving the symptoms of Crohn’s disease. Most of the drugs work by preventing inflammation in the intestines.

A group of anti-inflammatory drugs called aminosalicylates are usually tried first. Aminosalicylates are chemically related to aspirin. They suppress inflammation in the intestine and joints. They are given either as pills by mouth or by rectum, as an enema.

Certain antibiotics help by killing bacteria in irritated areas of the bowel. They may also decrease inflammation.

Antidiarrheal medications such as loperamide (Imodium) may be helpful if you have diarrhea.

Other more powerful anti-inflammatory drugs may be helpful. But they can also suppress your immune system, increasing your risk of infections. For this reason, they are not often used on a long-term basis.

The newest drugs approved for treatment of Crohn’s disease are tumor necrosis factor (TNF) inhibitors. These medications block the effect of TNF. TNF is a substance made by immune system cells that causes inflammation. TNF inhibitors have potentially very serious side effects. They are generally prescribed for moderate to severe Crohn’s disease that is not responding to other therapies. Infliximab (Remicade), adalimumab (Humira) and Certolizumab pegol (Cimzia) are TNF inhibitors.

Surgery to remove a section of the bowel is another possible treatment. In general, surgery is recommended only if a person has:

  • Bowel obstruction

  • Persistent symptoms despite medical therapy

  • A non-healing fistula

When To Call A Professional

New or changing symptoms often mean that additional treatment is needed. People who have Crohn’s disease should be in frequent contact with a doctor.

One serious complication is bowel obstruction. This occurs when the intestine becomes so narrowed that the digestive contents cannot pass through. Bowel obstruction causes vomiting or severe abdominal pain. It requires emergency treatment.

Other symptoms that require a doctor’s immediate attention are:

  • Fever, which could indicate infection

  • Heavy bleeding from the rectum

  • Black, paste-like stools

Prognosis

Crohn’s disease can affect people very differently. Many people have only mild symptoms. They do not require continuous treatment with medication.

Others require multiple medications and develop complications. Crohn’s disease improves with treatment. It is not a fatal illness, but it cannot be cured.

Crohn’s requires people to pay special attention to their health needs and to seek frequent medical care. But it does not prevent most people from having normal jobs and productive family lives.

It can be helpful for a newly diagnosed person to seek advice from a support group of other people with the disease.

Learn more about Crohn’s Disease

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PMC

Case presentation

The patients were all treated in our institute which is a tertiary referral centre for inflammatory bowel disease (IBD) in the Netherlands. We identified patients by a search of the morbidity database of the department of Gastroenterology and Hepatology which includes the ICD-9 diagnoses of975 patients with Crohn’s disease and 821 patients with colitis ulcerosa referred between 1973 and 2004 and by a search of the gastric emptying database which includes 239 patients who underwent a scintigraphic gastric emptying study in our hospital between 1999 and 2004. We selected cases with a diagnosis of IBD including Crohn’s disease and ulcerative colitis who also had an impaired gastric emptying by matching the two data bases. We identified four patients with Crohn’s disease and one with indeterminate colitis who were diagnosed based upon accepted radiological, endoscopic and histological criteria . We have reviewed the medical records of the cases who all had a severe symptoms of foregut dysmotility.

Because of persistent symptoms of nausea, vomiting and in some cases weight loss patients were thoroughly evaluated. All patients underwent a small bowel enteroclysis. None of the patients had signs of active inflammation or stricture. Colonoscopy with inspection of the terminal ileum was performed in every patient and biopsy specimens were taken for pathological examination. All patients underwent an upper gastrointestinal endoscopy to rule out active Crohn’s disease in the upper digestive tract and intestinal stenosis as cause of the symptoms. Random biopsies were taken from the gastric antrum and corpus. We found no mechanical obstruction in any of the patients and there were no endoscopical or histological signs of active Crohn’s disease. Furthermore there were no signs of inflammation in the laboratory studies. After having ruled out active inflammatory disease gastric emptying was evaluated by a scintigraphy in all patients.

Table ​Table11 summarizes clinical data of all patients. Remarkably all of them were females with a mean age of 38.6 years at the time of impaired gastric emptying (range 21 – 56 years). The mean duration of the disease was 9.4 years with a wide range from 2 to 26 years. One patient had small bowel involvement, in two the disease involved the small bowel and the colon, and in two it was limited to the colon. Two of the patients had undergone resection, colectomy with ileostomy (patient 4) and ileum resection twice (patient 2). Despite discouragement, three of the patients were smoking. The mean t 1/2 of gastric emptying was 234 minutes (range 110–380 minutes).

Table 1

Clinical data of the five patients

Patients 1 2 3 4 5
Diagnosis CD CD CD CD IC
Sex F F F F F
Age (yr) 21 29 38 56 57
Age at diagnosis (yr) 19 23 28 30 54
BMI (kg/m2) 37,4 33 31,4 22,3 19
Localisation Ileum-Colon Ileum Ileum-Colon Colon Colon
Resection No Ileum × 2 No Colectomy No
Stomy No No No Ileostomy No
Smoking Yes Yes Yes No No
T 1/2 (min) 380 288 220 110 171

CD, Crohn’s disease; IC, indeterminate colitis; BMI, body mass index

We describe one of the cases (case1) in more detail. This was a 19-yr-old female patient with a history of asthma presented to our outpatient clinic with complaints of abdominal pain and chronic diarrhea that had been present for approximately 5 months. She complained of continuous pain localized in the upper abdomen but she also had intermittent colic-like pain elicited by food ingestion, sometimes accompanied by nausea. There was watery diarrhea with a frequency of up to 10 times a day. She had anorexia and lost 15 kg of weight in the preceding 5 months. She had been taking diclofenac and she smoked 4 cigarettes per day.

On physical examination she had normal vital signs. Her weight was 84 kg with a length of 171 cm. There was a mild tenderness in the right lower abdomen. Further examination was not remarkable.

Initial laboratory studies revealed a sedimentation rate of 25 mm in the 1st hr, C-reactive protein of 40 mg/L, albumin 37 g/L (normal 36–53 g/L), haemoglobin was 7.8 mmol/L (normal 7.3–9.7 mmol/L), white cell count was 12.1 × 109/L (normal 3.5–11.0 × 109/L) with 75% neutrophils and thrombocytes were elevated (480 × 109/L; normal 120–350 × 109/L). Sigmoidoscopy revealed a patchy erythema with rectal sparing. Histopathology of the biopsy specimen showed chronic active inflammation without presence of granulomas. Barium examination of the small bowel demonstrated a narrowing of the distal ileum with thickening of the wall over a length of 40 cm.

A diagnosis of Crohn’s disease with involvement of left colon and terminal ileum was made and treatment was started with oral corticosteroids and azathioprine in combination with mesalazine. Because of adverse reaction (fever) to azathioprine and thereafter mercaptopurine, tioguanine was prescribed, and well tolerated.

One year and a half after the first presentation she complained of nausea, vomiting, early satiety, weight loss of 15 kg and diarrhea. Laboratory studies now showed no signs of inflammation. There were no endoscopic signs of activity of Crohn’s disease in colon, terminal ileum or stomach and duodenum. Biopsy specimens taken from the gastric antrum, duodenum, terminal ileum and colon revealed no active inflammation. Small bowel enteroclysis showed no stricture and the terminal ileum was now normal. Gastric emptying with radiolabeled pancake was severely delayed with a t 1/2 of 200 minutes and 3 months later with a t 1/2 of 380 minutes.

Tioguanine was stopped because of the remote possibility that the symptoms were secondary to the drugs, but this did not ameliorate the symptoms. Because of persistent foregut dysmotility symptoms nasojejunal feeding was initiated. Recently she underwent a Roux-Y gastrojejunostomy with introduction of an enterocutaneous jejunal feeding catheter.

Sydney was 3 when she started showing signs of sickness. She was vomiting at random times and it didn’t seem related to any particular foods or eating patterns. The incidents weren’t frequent, just once every two weeks or so, but this went on for about six months, and naturally worried her parents. Her pediatrician ruled out food allergies, but couldn’t identify a cause.

Then Sydney started getting lethargic. She wasn’t joining in activities at preschool, and she rarely felt like eating. Sydney also started getting fevers at night, so her pediatrician ordered blood work. The results showed indications of inflammation, which pointed to inflammatory bowel disease (IBD). There are two types of IBD, ulcerative colitis and Crohn’s disease, both chronic conditions that affect the gastrointestinal (GI) tract. Sydney didn’t have some of the common symptoms for IBD, such as diarrhea, so her parents, Amy and Keith, wanted confirmation of her diagnosis.

Finding an answer at CHOP

The family was referred to Children’s Hospital of Philadelphia (CHOP), where they met with pediatric gastroenterologists Robert N. Baldassano, MD, and Lindsey G. Albenberg, DO. Dr. Baldassano is Director of the Center for Pediatric IBD, and Dr. Albenberg is a researcher with the Center who specializes in treating patients with IBD. The Center for Pediatric IBD is one of the largest of its kind in the U.S.

Diagnostic tests were conducted, including an upper GI series and a colonoscopy, as part of which tissue samples (biopsies) were taken from the colon and ileum (the final section of the intestine). The tests confirmed that Sydney did in fact have Crohn’s disease, in an unusual presentation without diarrhea. The inflammation was in her ileum.

The doctors discussed a range of treatment options with the family, including medication and nutritional therapy. They settled on short-term treatment with a medication that reduces inflammation and stomach pain in patients with IBD, combined with longer-term nutritional therapy using a nasogastric (NG) tube passed into her stomach through her nose. With the NG tube, a pump pushes a measured amount of nutritional therapy formula into the stomach.

Sydney’s parents were shown how to insert the NG tube and how to use it to feed Sydney prescription formula. Sydney was given a measured amount of formula during the evening and overnight. During the evening sessions, she wore a backpack, and while she was sleeping the formula hung in a sack from a pole above her bed (in much the same way fluids are given in a hospital).

Sydney’s breakthrough: A special flower girl

“Within two weeks she was feeling better,” says Amy. “She was running around more and she was gaining weight. She had been skin and bones before.”

Sydney had been asked to be a flower girl for a wedding that fall, and the date was just two weeks after she began using the feeding tube. “We were nervous about how she would be the day of the wedding, considering how lethargic she had been for months,” says Amy. “We were also worried that the couple would be upset that her tube would be in for all the pictures. They couldn’t have been more understanding. Sydney brought her backpack to the reception and was dancing and having the best time while she was receiving her feeding.”

“she danced the whole night, which showed us her energy had returned. next to the wedding couple, she was the star of the event. we couldn’t have been happier.”

Sydney’s recovery continues under the care of Dr. Albenberg. She had been at the 30th percentile for height and weight in the months before she turned 4. Now 10, she’s at the 75th percentile for height and the 55th for weight.

‘They came through and then some’

Today, Sydney is an active, happy child. She’s engaged in a wide range of activities, including drama, chorus, band, hip hop and tennis. She’s active with her church youth group and is a well-rounded student.

She’s still supplementing her nutrition with the NG tube, but that has gotten easier over time. “It was very difficult at first,” Amy explains. “When we had to change the tube she would cry. We had to hold her still. Now I do it with her and it takes 30 seconds. She drinks cranberry juice while I do it, which helps guide the tube.”

The family feels lucky to have received their care at CHOP from a medical team with such deep expertise in treating IBD.

“Sydney’s medical team at CHOP have all been so comforting and supportive,” Amy says. “They told us they would get her into remission and they were right, which seemed hard to imagine at the time. They came through and then some. We are never rushed at our appointments. They take the time to answer all our questions and concerns, no matter how long as it takes. It feels like we are all a big family with the same goal of keeping Sydney healthy and finding a cure for IBD.”

Treatment will depend on site and extent of disease, severity of symptoms and the patient’s wishes.

Medical treatment: medicines commonly used in Crohn’s disease include:

  • 5-aminosalycylic acid (5-ASA) – 5-ASA drugs such as mesalazine (Asacol) are occasionally used in Crohn’s disease, but the evidence suggests that in general this class of drug is not effective for active Crohn’s disease. In addition, the 5-ASA group of drugs may help to maintain remission particularly after surgery but the data is not conclusive. 5-ASA enemas may help control local rectal Crohn’s disease.
  • Children with Crohn’s disease respond well to nutritional therapy (elemental diet). Adults do not seem to respond as well to children and generally nutritional therapy is used as adjunctive therapy in this group.
  • Corticosteroids – the main stay of treatment for active Crohn’s disease are corticosteroids which suppress inflammation. In severe cases intravenous treatment with hydrocortisone in hospital may be needed. Most patients use oral steroid preparations particularly Prednisolone starting with a high dose and gradually reducing. Budesonide a newer corticosteroid can be prescribed as it is believed to have fewer side-effects. Serious side-effects, particularly osteoporosis limit the long term use of corticosteroids.
  • Immunosuppressants – in patients with Crohn’s disease that recurs quickly when the steroids are reduced, azathioprine (eg Imuran) (or its similar drug 6-metacaptopurine (6MP) is often prescribed. Use of these drugs allow the steroid dosage to be reduced. However azathioprine has its own side-effects including liver and bone marrow toxicity and very careful medical supervision is required with these drugs. Methotrexate, another immunosuppressant, can substitute if azathioprine is not suitable but this is not thought to be as effective as either azathioprine or 6MP.
  • Over the last 10 years a new class of drugs have been available to treat patients with Crohn’s disease called monoclonal antibodies. The first in this class is infliximab (Remicade) and is widely used in patients with severe Crohn’s disease. It acts as a powerful immunosuppressive drug by blocking an important chemical in the blood which causes inflammation called TNF-α. This drug can increase a person’s chance of developing lots of different infections and must only be prescribed by physicians who have experience managing patients with severe Crohn’s disease. Other drugs of this class used in inflammatory bowel disease include adalimumab (Humira), certolizumab (Cimzia) and golimumab (Simponi).

What can be done at home?

Watch out for signs indicating that the disease is becoming worse:

  • blood in the stools
  • new or different abdominal pain
  • a fever which cannot be attributed to anything else
  • unexplained weight loss
  • occasionally extreme fatigue alone can herald the onset of active disease
  • joint pains (polyarthralgia) can indicate active inflammation in the gastrointestinal tract.

If you have these symptoms, contact your doctor.

Activity

  • Acute attacks require rest.
  • In periods of remission, the patient should try to resume their normal activities.

Diet

Normally, there are no restrictions but, as with other intestinal diseases, a low-fat and low residue diet may reduce the person’s diarrhoea.

Many patients report an improvement in their symptoms when they reduce consumption of lactose based food (eg milk, cheese and yoghurt). But no controlled trials have consistently demonstrated improvement in Crohn’s disease activity scores with low lactose based diets.

What are the complications of Crohn’s disease?

  • Stricturing (narrowing) of the bowel caused by long standing inflammation and scarring can cause bowel obstruction.
  • Bleeding.
  • Severe diarrhoea (this may have a number of different causes and may not be due to active disease alone).
  • Iron deficiency and other vitamin deficiencies, especially vitamin B12.
  • Ileus (reduced bowel mobility), or obstruction (partial or complete blockage of the intestine).
  • Perforation of the inflamed intestines or formation of fistulas.
  • Inflammation of the liver, joints and eyes, and skin rash.
  • Problems with digestion of food, either due to extensive scarring in the intestine, or because the intestine has become too short after a number of operations.

The above symptoms notwithstanding, most patients lead normal lives.

How is Crohn’s disease treated?

  • The treatment depends on the severity and extent of the disease, as well as the effect of the disease on the patient.
  • Medication can in many cases control the inflammation, keep the symptoms down, and reduce the probability of relapse.
  • Surgical removal of the affected areas is sometimes necessary, but the disease can recur elsewhere. There is an 80 per cent life-time risk of the need for surgery in those with Crohn’s disease.
  • Severe attacks require treatment in hospital.

Other people also read:

Blood tests: how is a blood test carried out?

X-rays: what happens during an X-ray test?

Iron deficiency: what are the symptoms of iron-deficiency anaemia?

Based on a text by Dr Jens Kjelsen, Dr Ove Schaffalitzky de Muckadell, professor of internal medicine

Last updated 07.10.2014

Dr. David Maxton Consultant Gastroenterologis at The Shrewsbury and Telford Hospital NHS Trust and Specialises in Gastrointestinal and Liver services J Butterworth Consultant gastroenterologist

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