I just got off the phone with Dr. Gray. I told her how much better I’m feeling, and she said she didn’t want to even test my pressure if I’m feeling this good. She doesn’t want to mess around with things.
She is very hopeful that I will continue to feel better. (me too!)
I am wondering if the reason I’m feeling so much better is because I stopped taking Topamax. It can lower your pressure, so it could have been causing my pressure to be too low. Or it could also be because I started taking B12 shots. Tomorrow will be week 3, so I should really be starting to feel a difference there. I have much more energy, and I just feel better. Perhaps a combination of the two has really made the difference. I don’t know, but I’m just grateful to be feeling so very much better!
What a difference from just a couple of months ago, huh?
Oh, I am talking on the phone again! I had 3 conversations on the phone today and I was able to hear the people, and I didn’t get nauseous. (often when I tried to talk on the phone before, even when I could hear, it made me so dizzy I would get sick to my stomach)
Because of the gastrointestinal troubles I’ve been having I have to take a series of three Breath Tests. The first one will test for abnormal bacteria growth in the intestines, the second test for lactose intolerance, and the third for fructose intolerance. If I have the first they can treat it with an antibiotic, the other two will require a life time diet change.
To start things off I had to go on a low carb/starch diet yesterday. I can’t eat anything for 12 hours before the test, and then the test last for 3 hours during which time I can’t eat of drink anything. I’m doing the first test today. I have had to give a breath sample, then drink a solution, then I have to give breath samples every 20 minutes. I can finally eat around 1:30pm today.
I will perform the second test on the 28th, and the final one on March 3rd. So tomorrow I have a normal day, then the low carb day again on the 27th, and the then the test on the 28th….and so on. During second and third test I only have to collect my breath every hour for 3 hours instead of every 20 minutes.
It will be interesting to see what these tests find. I’m kind of hoping the first one will be positive and they can just treat me with a pill, and I’ll be fine. I’m really tired of all the poking and prodding and not finding anything. I don’t think I have lactose intolerance, but I’ll deal with it if I do. No matter how much I love cheese! The fructose intolerance would also be pretty hard. Can you imagine never being able to eat fruit again? I don’t eat a lot of processed foods, but just think about how many things have fructose in them. Again, I would deal with it. Anything to get my gut working right again.
Right now I’m so very hungry, and I’m tired of blowing in this blue bag every 20 minutes. (The blue bag is attached to a needle that you insert in a test tube and you catch your breath in it. So at the end of this test I will have 10 test tubes filled with my hot air.) I now have a very bad headache, and I’m a bit dizzy. I know it’s because I’m hungry. When I went to the hospital today to pick up the tests and get instructions, I thought I was going to do the first one there, and then I could leave and eat. I had no idea that each of these tests last for 3 hours. One more thing, I have asthma, not bad, but all this blowing, is making it hard to breathe.
OK enough fussing, you can tell I’m hungry, I get a bit bitchy when I want food! : )
I have to say that the people at the hospital were so very nice. Most of my doctors are at Duke and I’m used to it there, this test was through Rex Hospital in Raleigh. The intake person was so very nice. When I explained that I’m hearing impaired and needed her to look at me when she spoke so I could hear her, she really listened! Most people, hear me, but then they don’t think about it and will talk to me while they are looking at their computer, or they speak really low. I have to say, most people just have no idea what it’s like to deal with a person who is hearing impaired. This lady even wrote in red ink on my papers that I was hearing impaired and needed for the other people who dealt with me to look at me when talking and speak clearly. I’ve never felt so at ease. Of course, Stuart was with me, so I have my own “interpreter”, but it is just so much easier when I don’t have to look at him after someone speaks to me and wait for him to tell me what they said. He is wonderful about it, although some people seem to get confused or irritated that I don’t answer them immediately and need to look at my husband to tell me what they said. I just don’t understand some people. But today I was very pleasantly surprised at how much I was treated with respect, and courtesy about my condition. It’s a shame I have to say surprised, but I simply haven’t found many places where the people are just so nice and go out of their way to make sure I can hear them and understand.
I will be letting the hospital know how impressed I was with my visit, especially with Barbara Kiplinger, the intake employee who took all my initial information.
Happy as a Monkey (I did this painting for a friend's nursery.)
It’s been 12 days since the Cerebral Spinal Fluid Patches, and I am feeling better.
I still feel better in the mornings, and then fade in the afternoon. By the evening I often just feel a bit icky. Kind of off kilter. (you know, a little off-balance, not much, a little nauseous…) However, over all, I do feel much better as far as the Meniere’s is concerned. Not so much with my GI stuff, and my hip pain, but that is a story for another day.
Stuart talked to Dr. Gray a couple of days ago and he told her how I felt so much better in the mornings, then as the day goes on I start to feel worse again. She said that is a sign of low pressure. She suggested I come in and have her patch the last leak. They didn’t patch them all because they were afraid they would spike my pressure, and/or cause it to raise and stay too high. We decided to wait a few more days to see how I’m doing. I’m thinking I should probably stop taking Topamax all together (after discussing it with Dr. Gray) before I go in to have the last patch. Topamax is used to help control migraines, and it also treats bi-polar disorder, however, it can also be used to lower your spinal fluid pressure. Since I’m taking a small dose every day, I think it’d probably be a good idea to get off of it if I already have low pressure. : ) Then we will see if I still need to go in for the last patch.
How much better do I feel?
I haven’t taken any Valium or Phenergan in days.
The dizziness and feeling of being off-balance (disequilibrium) is minimized. In the mornings I don’t feel it at all.
No headaches. (well, I had a little one today, but I think it’s because I didn’t sleep well last night. No migraines though!!)
Hearing is staying pretty steady in my left ear, I can hear pretty good out of it, but some frequencies are dull. My right ear is still pretty gone, but in the evenings the tinnitus is much worse in that ear.
So what do you think? Sounding good so far?
I learned from my last experience with the blood patch that I don’t want to jump the gun and think I’m ok before I have a long while feeling that way. I’ve been conversing with another patient of Dr. Kaylie and Dr. Gray. She has high pressure (and she doesn’t have Meniere’s she has another vestibular disorder). She felt “normal” for over 2 months then the meds stopped working and her symptoms started to return. It was so hard for me after just 10 days of feeling normal to go back to having the symptoms again, I can’t imagine how she must have felt after 2 months! She is still being treated, and there is hope she will get back to that “normal” state too. Just as we are hoping I will.
This time I’m looking at things differently. Before, I looked at this as a possible cure. I don’t know if I want to think of it that way. That would mean that it couldn’t come back, and we have seen that it can. I have finally come to accept this disease as a part of me, that I have to live with for the rest of my life. I will always look for the best way to deal with it, and right now I think this treatment is it, for me. However, I know that the Meniere’s is still there. If something gets off-balance again, it will all come back. One of my lovely readers advised me to not fight it so hard, but walk with this disease and accept it. I’ve taken her advice. It will never be my friend, but it will always be a part of me, and I can deal with that (at least I’m learning to). It has made things much easier since I started thinking this way.
Another thing I’ve been thinking about a lot lately. Friends. I feel like I’ve lost touch with so many of my friends since I started getting really sick. (I say really sick, because I’ve been sick for a long time, but I was functional. This past 2 years have been much harder.) I was taking that very hard. But I really needed to look at it and realize, that most of it had nothing to do with me. Most of my friends also had children over the past 2 years. I can’t drive, and their lives are so busy with their new families they just don’t have the time to make for me. And that’s ok. I’m still here. You know, even if it is because they don’t want to be around a sick person, that’s ok too. I’m not going to take it personally.
I decided I’ve had some really great friends in my past, and I love them and want the best for them. We may not be in touch as much right now, that’s ok. We may be more in touch in the future and that would be great, if not, then it wasn’t meant to be. I will still love and cherish the time we spent together. I know there will be new people in my life, and in theirs. We grow, sometimes we grow apart, sometimes we grow together. Sometimes we simply grow up. I think I’m doing a lot of that right now. (at 47, you would think I was all grown up….but I’m learning new things all the time, especially about myself. And heck, I don’t think I’ll ever see myself as a “grown-up”. *shudder*)
I know I haven’t been posting as much as I usually do, and I haven’t been talking about my progress after my Cerebral Spinal Fluid patches, but I just haven’t felt all that different.
I wake up in the morning, and most mornings I feel pretty good. (that’s not unusual) I continue to feel a bit off balanced all the time. As the day goes on I seem to start feeling a bit worse. I don’t really know how to explain it. It’s kind of like I’ve always felt, but different. My head feels full, and I feel like if I moved my head too much I’d barf. I feel slightly nauseous most of the time. If I get hot, it gets so much worse. I’m just not sure what it all means. Stuart tells Dr. Gray and she seems content. She says it’s good that I’m not having headaches. I’m happy about that too. I sure do wish I would see more improvement.
I do feel like my hearing is a bit better in my left ear, but I still have trouble hearing certain frequencies. I don’t realize just how much I rely on closed captioning until I don’t have it.
So, my progress so far…not too much. But I haven’t had any full blown Vertigo attacks!! That says a lot. One time I felt like I might start having one, I took a pill to reduce my pressure (like Dr. Gray advised) I was still having symptoms 30 mins later, so I took another one…and shortly afterward I couldn’t stand it any longer and took a Valium and Phenergan. I started feeling better, but I’m not sure what caused it.
I had a Gastrointestinal CT scan on Thursday. It was not a fun experience, but it wasn’t the worst I’ve had. I think I had a reaction to the Contrast they had me drink before the scan. I had horrible diarrhea starting before I started the 3rd cup. (you have to drink 3 cups of this stuff, they tell you that, but they don’t tell you the cups are 20 oz.). Well, they almost had a mess to clean off of their expensive machine.
The other bad thing about the test. They were also supposed to put in an intravenous dye. I told the nurse on the phone the day before that it is very hard to find my veins. So she took me back in the very cold CT room and tried to start and IV, she looked at my arms and said, “Oh, yeah, you told me this would be a challenge.” I said, “Yeah, I don’t know why people never seem to take me seriously.” She said she did, she just forgot. She then said she could see any veins, and she couldn’t even feel anything. I said, well, it’s very cold in here, they had to use a hot pack last week to help out. Well they didn’t have that.
So after 5 times of her trying to find a vein, and each time she would say something like, “I don’t feel confident about this, but I’m going to try.” I felt that was not the thing to say to a patient. She was very concerned for my comfort, but she was not confident in her job. One time when she said that and was about to stick me (try number 4 I believe) I turned to her and said, “Honey, You need to get some confidence, you have to believe you are going to do this or you will never be able to do it. Take control, tell that vein who is boss! And just do it! Don’t worry so much about hurting me, I’ve had much worse.” She just said, “You are so funny.”
OK, well, I do believe, if you believe you are going to fail, you will fail. It was obvious she believed she was not going to be able to do this and she never did. Finally, she had to call the radiologist and tell him that she couldn’t do it, he said fine. We just wouldn’t have that part, if they needed it later, they’d try again. I said, “with someone else giving me the IV.” : )
Luckily, it doesn’t seem to be a need for them to do that part of the scan. Yay!
The results? I have a Kidney stone! Well, that was a surprise. It’s small and not in a place where it’s causing any harm right now, but still, A Kidney Stone…crap. I just wouldn’t think it possible with as much water as I drink. Oh well.
The doctor also told me that I have a fatty liver, I don’t have liver disease though because my enzymes aren’t high. So it’s just fat there because I’m over weight. I told her, “Well that doesn’t surprise me since I gained 40 pounds in about 2 months, that is one of the reasons I came to see you.” She said, “A low-fat diet….yadda, yadda….” I told her that is what I was doing before all this started…she said I still needed to do the breath test to determine if I’m lactose or fructose intolerant. And then come in for another office visit to reassess. I told her I’m working with a nutritionist. She was great! (I thought, then why didn’t you suggest it?) Can you tell, I’m not impressed by this digestive health office?
She just keeps telling me to take fiber. Well, that didn’t work. I tried.
I’m glad my nutritionist doesn’t believe in a one size fits all philosophy. She is working with me to figure out the best diet for me, and how to get me healthier. One step at a time. Already working with her, my diarrhea has gotten better. I’m still having it sometimes, but not every day! Isn’t that exciting??
I’m still hopeful that the patches will work. Again, one step at a time.
Tomorrow is my hubby’s birthday. I gave him a gift certificate for a 90 minute massage. He had it yesterday. It was so nice to be able to pamper him for a change. And I’m going to watch the Super Bowl with him. (I’m not a sports person) We’ll have fun. Gluten Free pizza. Possibly wings. Oh, and Ice Cream from a local Dairy. (I won’t be having the ice cream, I’m not eating sugar right now, but it’s a great treat for Stuart. Perhaps I’ll put a candle in it.)
At about 3:30pm I was finally on my way home….it was a long day.
Tisseel
First, we went over everything and I signed all my consent forms. After talking Dr. Gray was pretty sure we’d find out that my pressure was again low, that the blood patches didn’t hold, and that she would be patching me up again today, but this time she was going to be using Tisseel, a surgical fibrin sealant indicated for hemostasis and tissue sealing. It looks like epoxy. It comes in a double tube plunger and it mixes when they insert it. (kinda cool huh?)
So I went through the same thing I went though when I got the blood patches, but I didn’t have to have another myelogram. They just used the information from the first one. I don’t have to be as careful after this procedure because this sealant doesn’t have to clot around the leak, it is sealed now. However, since they put less stuff in I will feel the results more gradually instead of feeling it as quickly as I did last time.
I have noticed I can tell that I am hearing better. (the TV was too loud! hahaha) I’m less dizzy that I have been, but I don’t think I’d risk closing my eyes and shaking my head around yet…maybe tomorrow. : )
Dr. Gray said I could walk around some tomorrow, but as sore as I am right now, I don’t know if much of that is going to be happening. It’s not horrible, but dang my back hurts. I hate taking pain pills, but I think I will be taking a couple tonight.
There is still a risk that my pressure may spike tonight, but I have meds to take care of that if it happens. So far, no headache, so no sign of increased pressure.
When I left Dr. Gray shook my hand and told me that she hoped she wouldn’t need to see me again! I must say, as much as I like her, I also hope I don’t have to see her again either. She is such a great doctor. You rarely meet a doctor who is so up beat and genuinely loves her job. When you are with her you can’t help but catch the enthusiasm and hope that just flows off of her.
Here’s Sandy coming to check on my recovery:
Sandy checking on me.
Tonight my darling husband went and picked up a gluten-free pizza from Mellow Mushroom. (what a treat!) Now I’m going to relax on the couch and watch cartoons. Maybe, we’ll turn on a movie, but right now cartoons are making me happy!
Right now I’m not feeling all that great. I think the meds aren’t sitting well, and I didn’t sleep very well last night. I sure hope I start feeling better soon.
I’ll let you know how I’m feeling tomorrow.
Thank you, everyone, for being so very sweet and sending me wonderful wishes. I really do appreciate all your thoughts and prayers.
A Zen Moment. (a commissioned painting by Wendy Holcombe)
Tomorrow I go in to see Dr. Gray again for another lumbar puncture and possibly having some spinal fluid leaks patched. They called today and moved my appointment up one hour so my lumbar puncture is at 11am tomorrow instead of at noon. I need to be there at 10:30am. Yay, that means I will be able to eat sooner!
Today, I woke up with a cold. It’s not bad yet, a slight sore throat, nose is running, don’t want to stay awake, head hurts, all brain foggy, achy all over…you know. I’m a little worried about tomorrow though. You have to be very still on the table when you get a lumbar puncture (after all, they are inserting a needle between 2 of your lumbar vertebra), what if I sneeze? Don’t know why I’m worried about that, I’ve only sneezed twice today.
I’m glad I have the appointment tomorrow. I’m really ready to see if we can’t get this figured out, but I am a bit nervous about having a cold. Even if I don’t sneeze or have the need to move, I am not going to be comfortable on that table, after all the table is hard and I already ache all over. However, I do want you all to know that a lumbar puncture is not like it used to be, they do not hurt. The only pain I really feel is the pain killer they inject first and it’s just a little sting. Then I feel a little pressure. But it’s not scary, and it doesn’t hurt. So no worries. I’m just a little apprehensive because I don’t feel good.
I will have to find a “Zen Moment” to keep myself calm and still. (actually, I just didn’t have a perfect picture for this post, so I thought I would shamelessly post one of my own paintings. *smile*)
I may be a tiny bit worried about having a cold during the procedure, but really, I’m mostly excited to get this over with. (I really hope they are planning on doing patches tomorrow and not just doing a lumbar puncture. Truthfully, I just don’t know.)
I have an appointment with Dr. Gray on January 28th at noon.
I don’t know why all of a sudden they were able to get me in sooner, but I’m glad.
We’ll find out what’s going on with the Cerebral Spinal Fluid Pressure. Hopefully, she will be able to get something straight. Even leveling things out a little would help a lot. 3-4 attacks a week are driving me crazy. (as you all know.)
On a side note. I made Sauerkraut today….well I started the making of Sauerkraut today. I thought I had pictures of it from the last time I made it but I can’t find them. : ( So I didn’t take any today. But I will tell you what I did. It is so easy!! (especially if you have a food processor) *this recipe was inspired by the recipe for Raw Sauerkraut in the Whole Life Nutrition Cookbook.
Sauerkraut
1 head of Cabbage
1 – 2 Tablespoons of Sea Salt (I use 1, but the original recipe called for 2)
Peel off a few of the out leaves of the cabbage head. Save these you will use them later. Chop the head into small enough pieces to fit in your food processor. (be sure to remove and discard the stalk. I really like the center of the stalk, I always just gobble it up.)
Slice up the cabbage in your food processor with your slicing blade. (if you don’t have a food processor you can do this by hand, but it will take a while, you have to cut it up really small.) Transfer the cabbage to a bowl and toss with the salt.
Here’s the really hard part if you don’t have a food processor. Remove the slicing blade from the food processor and put in your little plastic blade. Return cabbage to food processor in small batches just smashing it up and making it all juicy. (if you don’t have a food processor you need to just keep smashing he cabbage with a mallet until you get a lot of the juice out. Of course, this is a great way to get your frustrations out.)
Just spoon your juicy cabbage into a clean jar, and cover with those outer leaves you saved from the beginning. Press the mixture down so the is some juice covering the leaves. This won’t be hard. Keep in a dark dry place for 3-7 days, I like to keep mine in my pantry. (I do put the lid on the jar, but I don’t tighten it.) Every day you need to press it down some more so even more juice will cover those leaves. (eventually the leaves will start to just fall apart, don’t worry about it.) The original recipe says to start tasting it after about 3 days, mine tastes nasty that soon. Just smell it, if it smell like sauerkraut, then taste it. If it taste like you like, then put it in the refrigerator the slow/stop the fermentation process. If you get a funky scum on the top of your sauerkraut, just spoon it off.
I use a wooden pestle from a mortar and pestle that I have to press my mixture down every day. Since I don’t use this mortar and pestle any more, I use it exclusively for this, now it smells like pickles. : ) If you used a pestle made from a different material, or perhaps a mallet, you probably wouldn’t have this problem.
They do make crocks just for making sauerkraut, and I’ve seen much more complicated recipes, but I’ve never tasted better sauerkraut.
I may make it a different way some time, I may even get a fermenting crock so I can make more than one head of cabbage at a time. But for now, this method does well for me, I just start a new jar before the one in the fridge gets empty.
(If I find those pictures, I’ll post one. Maybe I will take a picture of the jar I have started at least so you can see what it looks like.)
The last couple of days have been filled with accomplishments.
The biggest one first. Yesterday I didn’t have to take Valium or Phenergan all day long. (I did take it once today, but only once, I’m not positive I needed them, but I was starting to feel a little dizzy and better safe than sorry.) That’s a huge improvement.
I made dinner last night. To read all about what I made, check out my blog post on Wendy Cooks. (a little teaser here: it includes Acorn Squash and wild rice.)
I cleaned up the kitchen today.
I completed messed up the kitchen again today.
I made experimented with dinner again, and made something that I was very pleased with. I will post about it on Wendy Cooks tomorrow. (Yes, I made Pesto out of Kale! can you believe? I served it over penne pasta and grilled chicken…you must see the photos, I promise I will post them tomorrow.)
Stuart talked to Dr. Gray today, and she is setting up an appointment for me to come and have another lumbar puncture (also known as a spinal tap.) She mentioned that my pressure may still be a little high, but the Diamox is just too strong and they might put me on Topamax instead. Stuart mentioned that my psychiatrist just put me on Topamax, and she thought it was interesting that within the past few days I’ve started feeling better. They are now taking me off of the diuretic that I’ve been on from Dr. Kaylie. (I feel like such a trial and error patient….let’s see if this works…nope? well how about this?…a little…well how about this….) I guess we’ll see what the lumbar puncture says.
When I look at my little list it doesn’t look like I really got all that much accomplished, but I really do feel like I got a lot done. I didn’t have to lie still on the couch pumping in drugs praying not to throw up. I even let the dog out a few times and didn’t have to call Stuart down from work to do it.
Oh, and we had another winter storm here last night.
This winter has been very unusual here in Durham, NC. It’s never this white.
There is nothing like having a camera stuck down your throat. Yes I have a sore throat now, and my tummy is not feeling great. I think they topped the gas off too. Whew!
Well, this test shows I have Acid Reflux, and a little Gastritis. (he still wants me to have the CT scan to make sure my bowels aren’t doing something funny where the cameras just don’t reach. I thought, geez, you put a camera up one way, now you’ve put a camera down the other way, you mean there is still more you can’t see?)
My official paper that he gave me says that my “Z-line is irregular, 37cm from incisors”, and I have “Gastric mucosal abnormality characterized by erythema. Biopsied.”
Ok, so I looked up with a Z-Line Irregularity means. It mainly appears to mean that it shows I have acid reflux, but I’ll know more after the biopsy. And the 37cm from incisors is just how they measure where the Z-Line starts in people (or maybe where the irregularity is). Mine is 37 cm (or 14.6 inches) from my front teeth.
The other part: “Gastric mucosa abnormality characterized by erythema.” Simply means I have a little bit of gastritis but it’s not bleeding. Erythema means that it’s read and inflamed but it turns white when you press on it, so no bleeding. (hopefully) It also sounds like I have a bit too much mucus.
He put me on Prevacid. I’ve been on this medication before, for years actually. I don’t like being on this for so long, but I’ll do it for now. He also told me to follow an anti-reflux regimen indefinitely. That should be fun.
This is the Anti-Reflux Diet:
NO:
Caffeinated Drinks
Carbonated Drinks
Greasy or Fatty Foods
Spicy Foods
Citrus fruits or juices
Tomatoes or tomato bases
Onions
Peppermint
Chocolate
Alcohol
Nicotine.
Ok, so most of these are no big deal for me, but NO TOMATOES? or even worse NO ONIONS? If you have read my recipes you will know that I cook with onion and garlic all the time!
What I can eat and drink:
water or herbal tea
Skim milk, low fat milk, low fat yogurt, low fat or fat free sour cream and cream cheese, and low fat cottage cheese (WAIT A MINUTE HERE, THEY DON’T MENTION ANY REAL CHEESE AT ALL, NOT EVEN LOW FAT CHEESE…I DON’T THINK THAT’S RIGHT.)
Any Plain raw, baked, broiled, or steamed vegetable, Except Onions and Tomatoes.
Any Plain Raw, Broiled or baked Fruit (Except Citrus)
Any Plain Baked, Broiled, Steamed lean beef, pork, chicken, poultry, or fish.
Any low fat bread or Cereal, plain rice, plain pasta (Of Course, I can only have the Gluten-Free Version of these.)
Low Fat desserts (less that 3 grams of fat per serving)
Any fat free or low fat soup without tomatoes or onions.
This is going to be a challenge. The biggest challenge will be, No tomatoes (I love a good tomato sauce, I can’t stand them raw, but I love a good sauce.) No Onions! Oh my goodness. What will I do? I found there is an Indian herb called Asafoetida that when used in cooking gives the flavor of onion and garlic. I guess I will try that. Supposedly before it is cooked it smells like stinky feet and poop…that should be interesting. Oh, and cheese, that will be hard. But I guess I can use vegan cheese. I do like the Dayia Cheese.
As I said, a challenge, especially since we have a lot of cheese in the house. 🙂 Hopefully, it will make my tummy feel better, and I can stop running to the bathroom so much. That will make it all worth it I guess.
As I’ve mentioned before I’ve been having gastrointestinal issues for the past few months. I’ve been thorough a battery of test, including a colonoscopy, but they haven’t found anything. Now I’m in for even more test.
I have to have Breath Tests done.
The Hydrogen Breath Tests I will be having will be checking for Small Bowel Bacterial Overgrowth, Lactose Intolerance, and Fructose Intolerance. It will be interesting to see if these test find anything abnormal. (being fructose intolerant would be pretty difficult, but at least I’d know what the problem is.)
I’m also going to be having a CT- Endoscopy. They are going to give me this dye and take pictures of my upper GI tract,