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Patients' Information

Acidity


acidity acidity
What is Acidity?

Acid reflux is also known as heartburn, acid indigestion, or pyrosis. It happens when some of the acidic stomach contents go back up into the esophagus. Acid reflux creates a burning pain in the lower chest area, often after eating. If acid reflux symptoms happen more than twice a week, it means you have an acid reflux disease, also known as gastroesophageal reflux disease (GERD).

What Causes Acid Reflux Disease?

One common cause of acid reflux disease is a stomach abnormality called a hiatal hernia. Normally, the diaphragm helps keep acid in our stomach. But if you have a hiatal hernia, acid can move up into your esophagus and cause symptoms of acid reflux disease.

These are other common risk factors for acid reflux disease:

  • Eating large meals or lying down right after a meal
  • Being overweight or obese
  • Eating a heavy meal and lying on your back or bending over at the waist
  • Snacking close to bedtime
  • Eating certain foods, such as citrus, tomato, chocolate, mint, garlic, onions, or spicy or fatty foods
  • Drinking certain beverages, such as alcohol, carbonated drinks, coffee, or tea
  • Smoking
  • Being pregnant
  • Taking aspirin, ibuprofen, certain muscle relaxers, or blood pressure medications


Symptoms


  • Heartburn
  • Regurgitation
  • Early satiety
  • Bad test in the mouth
  • Post prandial fullness
  • Bloating
  • Bloody or black stools or bloody vomiting
  • Burping
  • Dysphagia -- a narrowing of your esophagus, which creates the sensation of food being stuck in your throat
  • Hiccups that don't stop
  • Wheezing, dry cough, hoarseness, or chronic sore throat

Red Flag


  • Age > 50 year, with new onset symptoms
  • Family history of upper-GI malignancy
  • Unintended weight loss
  • GI bleeding or iron deficiency anemia
  • Progressive difficulty in swallowing
  • Pain while swallowing
  • Persistent nausea and vomiting
  • Jaundice

Precipitating factors


  • Dietary indiscretion (high fat, caffeine)
  • Analgesic abuse
  • Some prescription medications (ASA, Calcium channel blockers, bisphosphonates)
  • Excessive alcohol use
  • Smoking

Dyspepsia and H.Pylori


Prevalence of H.Pylori is high in the developing countries. Approximately 80% of Indian population has antibodies against H.Pylori in their sera. Dyspeptic symptoms score are generally significantly higher in patients infected with H.Pylori and it improves with anti-H.Pylori treatment.


Complications, if untreated


  • Upper gastrointestinal bleeding
  • Stomach and duodenal perforation
  • Gastric outlet obstruction
  • Malignancy

Recommendations


  • Patients with dyspepsia who are older than 50 years of age and/or those with alarm features should undergo endoscopic evaluation.
  • Patients with dyspepsia who are younger than 50 years of age and without alarm features may undergo an initial test-and-treat approach for H. pylori.
  • Patients who are younger than 50 years of age and are H. pylori negative can be offered an initial endoscopy or a short trial of PPI acid suppression.
  • Patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy.

Can Acid Reflux Disease Be Treated With Diet and Lifestyle Changes?


One of the most effective ways to treat acid reflux disease is to avoid the foods and beverages that trigger symptoms. Here are other steps you can take:

  • Eat smaller meals more frequently throughout the day.
  • Quit smoking.
  • Put blocks under the head of your bed to raise it at least 4 inches to 6 inches.
  • Don't eat at least 2 to 3 hours before lying down.
  • Try sleeping in a chair for daytime naps.
  • Don't wear tight clothes or tight belts.
  • If you're overweight or obese, take steps to lose weight with exercise and diet changes.
Carcinoma Stomach

carcinoma stomach

Gastric malignancies are a major cause of morbidity and mortality in the world.

Globally, it is the second commonest site of cancer second only to lung in male accounting for 7.36 million deaths worldwide.

China leads with age adjusted incidence rate of 145.4 followed by USA with 43.4 in population based cancer registry worldwide.

National Cancer Registry Program by Indian Council of Medical Research (ICMR) states that stomach cancer occupies the leading site (9.1%) in Chennai, fourth leading site (6.4%) in Bangalore, and fifth (5.4%) in Dibrugarh. In Kolkata, it is the ninth leading cause of cancer (3.88% of all sites).


Symptoms

  • Significant weight loss
  • Discomfort or abdominal pain in upper abdomen
  • Vomiting
  • Early satiety or feeling of full or bloated after small meal
  • Difficulty in swallowing
  • Blood in vomitus
  • Blood in stool or black colored stool

Risk factors


  • Family history of carcinoma stomach
  • Long term inflammation of the stomach
  • H.Pylori infection
  • Previous stomach surgery
  • Smoking
  • Alcohol
  • Diet high in smoked food, salted food and pickled
  • Lack of physical activity
  • obesity

Diagnosis


  • Upper GI Endoscopy- it’s a safe and short day care procedure in which a flexible lighted tube is passed to look in to the stomach and initial part of small intestine
  • Biopsy- when some suspicious tumor or lesion is found on endoscopy , the tissue can be taken with a forcep for tissue biopsy

Staging


to look for how much the cancer has spread in stomach, to surrounding structures and other organs to plan best line of management

  • Endosonography (EUS) - EUS uses the high frequency ultra sound waves to detect the smallest lesion in the wall of stomach or other organs. This is the most accurate modality for detecting early cancer as well as smallest nodes which can be missed by conventional imaging.
  • CT Scan
  • Chest X-Ray
  • Laparoscopy

Prevention


  • Diet high in fresh fruits and vegetables
  • Avoid smoking, alcohol and tobacco
  • Avoid eating smoked, salted, pickled and fermented food

Treatment


  • Endoscopic mucosal resection (EMR)- minimal invasive endoscopic treatment of early stomach cancer
  • Surgery
  • Chemotherapy
  • Radiotherapy
  • Palliation

Inflammatory bowel disease (IBD)


colitis

Inflammatory bowel disease can cause symptoms such as abdominal cramps, bloody diarrhea, and fever. Other symptoms of IBD can include weight loss.

Inflammatory bowel disease (IBD) is characterized by two major disorders, Ulcerative Colitis (UC) and Crohn’s Disease (CD). Genetics and environmental factors are considered in the patho physiology of these multi factorial disorders. Due to the effect of both genetic and environmental factors on the etiology of IBD, variations exist in the epidemiology an incidence of these disorders worldwide.


Ulcerative Colitis


The highest annual incidence rate is 24.3 per 100,000 person-years in Europe compared to 6.3 per 100,000 person-years in Asia and the Middle East.


Types

Ulcerative colitis is classified according to the location of inflammation and severity of symptoms:

  • Ulcerative Proctitis - Inflammation is confined to the area closest to the anus (rectum), and rectal bleeding may be the only sign of the disease. This is the mildest form.
  • Proctosigmoiditis - Inflammation involves the rectum and lower end of the colon. Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so.
  • Left-sided colitis - Inflammation extends from the rectum up through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss.
  • Pancolitis - Pancolitis often affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight loss.
  • Acute severe ulcerative colitis - Previously called fulminant colitis, this rare form of colitis affects the entire colon and causes severe pain, profuse diarrhea, bleeding, fever and inability to eat.

Crohn’s Disease

Crohn's disease may involve inflammation in different parts of the digestive tract in different people. The most common areas affected are the last part of the small intestine (ileum) and the colon. Inflammation may be confined to the bowel wall, which can lead to narrowing from inflammation or scarring or both (fibrostenosis), or may tunnel through the bowel wall (fistula). Narrowing may lead to a blockage (obstruction).

The highest annual incidence is 20.2% per 100,000 person-years in North America in contrast to 5 person-years in Asia and the Middle East. Both incidence and prevalence of CD and UC is increasing over time, in both Western and developing societies.


Symptoms

IBD symptoms vary from person to person - and usually over time. IBD is a chronic (long term) disease and if you have IBD you will probably have periods of good health (remission) and then relapses or 'flare-ups' when the symptoms get worse.

  • Abdominal pain and severe cramps when passing stools
  • Diarrhea (sometimes mixed with blood, especially in ulcerative colitis)
  • Generalized weakness / fatigue /unwell
  • Loss of appetite
  • Weight loss
  • Anemia
  • Swollen joints, mouth ulcers and eye problems

Complications, if untreated

  • Hemorrhage- profuse bleeding from ulcers
  • Bowel perforation
  • Severe Dehydration
  • Malnutrition
  • Osteoporosis
  • Strictures and obstruction (narrowing of the bowels)
  • Fistulas and perianal disease
  • Toxic mega-colon (excessive dilation of the colon)
  • Malignancy
  • Arthritis
  • Eye disorders- iritic, uveitis, episcleritis
  • Inflammation of skin, joints & eyes
  • Mood disorders- anxiety and depression
  • Increased risk of blood clots in veins and arteries
  • Liver disorders- nonalcoholic fatty liver disease

Causes

  • The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but don't cause IBD.
  • One possible cause is an immune system malfunction. When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too. Heredity also seems to play a role in that IBD is more common in people who have family members with the disease. However, most people with IBD don't have this family history.

Risk factors

  • Age - Most people who develop IBD are diagnosed before they're 30 years old. But some people don't develop the disease until their 50s or 60s.
  • Race or ethnicity - Although whites have the highest risk of the disease, it can occur in any race. If you're of Ashkenazi Jewish descent, your risk is even higher.
  • Family history - You're at higher risk if you have a close relative — such as a parent, sibling or child — with the disease.
  • Cigarette smoking - Cigarette smoking is the most important controllable risk factor for developing Crohn's disease. However, smoking may provide some protection against ulcerative colitis. The overall health benefits of not smoking make it important to try to quit
  • Isotretinoin use - may be a risk factor for IBD, but a clear association between IBD and isotretinoin has not been established.
  • Non-steroidal anti-inflammatory medications - These medications may increase the risk of developing IBD or worsen disease in people who have IBD.
  • Where you live - If you live in an urban area or in an industrialized country, you're more likely to develop IBD. Therefore, it may be that environmental factors, including a diet high in fat or refined foods, play a role. People living in northern climates also seem to be at greater risk.

Recommendations

  • Ileo-colonoscopy is strongly recommended for evaluation of IBD and differentiating ulcerative colitis from crohn’s disease and other diseases causing similar symptoms
  • Mucosal biopsy specimens are important to diagnose and differentiate between the causes of such symptoms
  • Colorectal cancer risk is increased in both ulcerative colitis and extensive Crohn’scolitis and surveillance colonoscopy with multiple biopsies should be performed every 1 to 2 years

Treatment

Treatment for IBD involves a combination of self-care and medical treatment. Dietary and lifestyle changes may be helpful in managing your symptoms. It's important to talk with your doctor about ways to modify your diet while making sure you get the nutrients you need. For instance, depending on your symptoms, the doctor may suggest that you reduce the amount of fiber or dairy products that you consume. Also, small, frequent meals may be better tolerated. In general, there is no need to avoid certain foods unless they cause or worsen your symptoms

You may recommend a low-residue diet, a very restricted diet that reduces the amount of fiber and other undigested material that pass through your colon. Doing so can help relieve symptoms of diarrhea and abdominal pain. Be sure you understand how long you should stay on the low-residue diet, because it doesn't provide all the nutrients you need. Your doctor may recommend that you take vitamin supplements.

Another important aspect of self-care is to learn how to be stress free, stress may worsen your symptoms. Learning to meditate, creating time for yourself, and regular exercise are all important tools for reducing the amount of stress in your life.

Participating in a support group puts you in contact with others who know exactly the effect IBD has on your day-to-day life, because they are going through the same things you are. They can offer support and tips on how to deal with symptoms and the effect they have on you.


Medical Treatment

The goal of medical treatment is to suppress the abnormal inflammatory response so intestinal tissue has a chance to heal. As it does, the symptoms of diarrhea and abdominal pain should be relieved. Once the symptoms are under control, medical treatment will focus on decreasing the frequency of flare-ups and maintaining remission.

Colon Cancer

colon cancer

Colorectal cancer is a major cause of morbidity and mortality throughout the world. It accounts for over 9% of all cancer incidences. It is the third most common cancer worldwide and the fourth most common cause of death. Worldwide, colorectal cancer represents 9.4% of all incident cancer in men and 10.1% in women.

Bowel cancer is the fourth most common cancer in the UK, after breast, lung and prostate cancers. Around 40,700 people are diagnosed with the disease each year. In the United States, colorectal cancer is the third most common cancer diagnosis among men and women. It ranges from more than 40 per 100,000 people in the United States, Australia, New Zealand, and Western Europe to less than 5 per 100,000 in Africa and some parts of Asia

Worldwide mortality attributable to colorectal cancer is approximately half that of the incidence. It is estimated that 394,000 deaths from colorectal cancer still occur worldwide annually.

Colorectal cancer incidence is influenced by improved diagnostic techniques and screening programs. When bowel cancer is caught at the earliest stage, more than nine in 10 people will survive for more than five years.

Colorectal cancer survival is highly dependent upon stage of disease at diagnosis, and typically ranges from a 90% 5-year survival rate for cancers detected at the localized stage; 70% for regional; to 10% for people diagnosed for distant metastatic cancer.


Risk factors


  • Age – the likelihood of diagnosis of colorectal cancer increases after the age of 50
  • Personal history of adenomatous polyp- tubular and villous adenoma is precursor lesions for development of colon cancer
  • Personal history of inflammatory bowel disease- the relative risk for increase in colon cancer is 4 – 20 folds
  • Family history of colorectal cancer or adenomatous polyps- up to 20% of people who develop colorectal cancer have other family members who have been affected by this disease
  • Inherited genetic risk- Approximately 5 to 10% of colorectal cancers are a consequence of recognized hereditary conditions
  • Environmental risk factors- include a wide range of often ill-defined cultural, social, and lifestyle factors
  • Nutritional practices- Diets high in fat (especially animal fat), diet low in fruits and vegetables are a major risk factor for colorectal cancer
  • Physical activity and obesity- physical inactivity and excess body weight
  • Cigarette smoking- 12% of colorectal cancer deaths are attributed to smoking
  • Heavy alcohol consumption- regular consumption of alcohol may be associated with increased risk of developing colorectal cancer

Diagnosis


  • Colonoscopy
  • FOBT (fecal occult blood test)

Screening Guidelines


  • If you don’t have an increased risk of colorectal cancer because of your personal or family medical history, we recommend screening tests, beginning at age 45
  • Colonoscopy every 10 years
  • A yearly test for blood in the stool every five years
  • If you have an increased risk of colorectal cancer because of your personal or family medical history,
  • You should have a colonoscopy every 5 years beginning at age 40, or younger if hereditary non-polyposis colorectal cancer (HNPCC) is suspected.
  • For first-degree, direct relatives of patients with colorectal cancer that has presented before age 50
  • Screening should begin 10 to 20 years before the age of the diagnosed patient. For example, if your father is diagnosed with colorectal cancer at age 48, then you should begin your own colorectal cancer screening between ages 28 and 38
Constipation

Constipation

constipation

The incidence of constipation is over 10% worldwide and over 15% in India.

In Western society constipation probably occurs more than in other cultures – one in six people. It is estimated that as many as one young woman in every 12 suffers with constipation, mainly in their late teens to 20s.

Constipation is more frequent in individuals 65 years of age or older. Elderly people report problems with constipation five times more frequently than younger people.

In the elderly, up to 50% self-report constipation and up to 74% use laxatives daily.

Around 2% of the population suffers recurrent and constant constipation and is more common in women than in men.


Causes


Functional problems


  • Medications- side effect of wide variety of prescribed and over the counter drugs (few examples- codeine, iron tablets)
  • Pregnancy and after child birth- the gut slows down in the pregnancy due to hormonal changes
  • Following an operation- the painkillers given after surgery often causes constipation by slowing down the bowel. Food intake may also be erratic or even non-existent. Some major pelvic operations can lead to damage of the pelvic nerves
  • Eating disorders- patients who fail to eat regularly cannot expect a regular bowel action
  • Life style and bowel habits- People sometimes feel unable to open their bowels at school or in their workplaces. Over the years, their gastrointestinal tract gradually slows down and they become constipated
  • Psychological disturbances
  • Sexual and physical abuse- mostly during childhood
  • Fear of pain while passing stool

Anatomical problems


  • Rectocoele- bulging of rectum
  • Hirschsprung’s disease
  • Mega colon or mega rectum- large dilated colon
  • Nerve disease or injury

Complications


  • Rectal prolapsed
  • Fecal impaction

Investigations for diagnosing the cause of constipation


  • Ileo-colonoscopy- evaluation of cause for symptoms on the bowel lining
  • Ano rectal physiological testing- this test takes about 15 minutes and looks at the way the muscles and nerves of the rectum and anus are working
  • Transit studies
  • Dynamic MRI defaecography
  • Defaecating proctography

Treatment options


  • Lifestyle modifications
  • Dietary modifications
  • Medications
  • Biofeedback
  • Surgery- a rare sub set of patient require surgery
Diarrhea

diarrhea

diarrhea

Diarrhea is the passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual

Disease Problem


It has been estimated that in any given 24 hr period, 200 million people on earth have gastroenteritis

Estimated incidences in industrialized countries are 0.6 episodes per immuno-competent adult per year. Based on ratios between adults and children, estimated incidence in developing countries is 1.0-1.5 episodes per immuno-competent adult per year

Diarrheal disease is the second leading cause of death in children under five years old, and is responsible for killing around 760 000 children every year


Causes


There are many causes. Diarrhea often is caused by an infection with bacteria, viruses or a parasite. Bacteria cause diarrhea either by invading the intestine or by producing a toxin that makes the intestine secrete more water. When the diarrhea is caused by food contaminated with bacteria or parasites, people often refer to this as food poisoning

Other causes of diarrhea include:

  • Irritable bowel syndrome, especially during times of increased stress
  • Side effects from medications, such as antibiotics and magnesium-containing antacids
  • Overuse of laxatives
  • Inflammation of the intestine (ulcerative colitis or Crohn’s disease)


Symptoms


People with diarrhea usually have loose, watery stools. Less commonly, people pass frequent, small amounts of loose stool with mucous and blood.
Other symptoms can include:

  • Abdominal pain and cramping
  • Vomiting
  • Fever
  • Chills
  • Bloody stools
  • Lack of bowel control

Frequent vomiting and diarrhea can lead to dehydration (abnormally low levels of body water) if too much fluid is lost from the body.
Signs of dehydration include:

  • Dry mouth
  • Thirst
  • Dry eyes
  • Infrequent urination

Diagnosis


  • Detailed history and complete physical examination is necessary to rule out the cause of diarrhea
  • Stool routine and microscopic examination
  • Ileo-colonoscopy
Hiatus Hernia

hiatus hernia

Hiatus hernias affect anywhere from 1 to 20% of the population. Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES).

People of all ages can get this condition, but it is more common in older people.


Types of Hiatus Hernia


1. Sliding Hiatus Hernia


95% of hiatus hernia is "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach.


2. Rolling or Paraesophageal Hiatus Hernia


Only 5% of the hiatus hernia is the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm.


Symptoms

- In most patients, hiatus hernia cause no symptoms


  • Heart Burn
  • Regurgitation
  • Bleeding and Anemia
  • Difficulty in Swallowing
  • Chronic Cough
  • Wheezing
  • Pneumonia

Who is at risk for development of hiatus hernia?


  • Old People
  • Pregnancy
  • Chronic Cough
  • Chronic Vomiting
  • Chronic Constipation
  • Low Fiber Diet
  • Obesity
  • Ascites
  • Chronic Esophagitis

Red flag signs- When to seek urgent medical care?


  • Blood in vomiting
  • Black colored stool
  • Severe abdominal pain
  • Severe chest pain

Diagnosis

  • Upper GI Endoscopy- During this procedure, after you are sedated, an endoscope which is a thin, flexible, lighted tube was passed down your throat to check for any abnormality
  • High resolution manometry
  • PH Testing

Prevention

  • Treatment of ascites, chronic cough, vomiting and constipation
  • Healthy diet, avoid western fiber depleted diet
  • Control weight

Treatment options

1. Lifestyle modifications

  • Eating smaller, more frequent meals rather than three large meals a day
  • Avoiding lying down (including going to bed) for three hours after eating or drinking
  • Removing any foods or drinks that make your symptoms worse from your diet
  • Control your weight

2. Medications

3. Surgery

  • Only reserved for emergency situations and in patients who aren’t helped by medication and life style modifications
Jaundice

jaundice
jaundice

Jaundice is described as a yellowish discoloration of urine, eyes and skin

Signs


  • Yellowing of the skin, eyes and mucus membrane (the lining of the body's passageways and cavities, such as the mouth and nose)
  • Pale-colored stools (feces)
  • Dark-colored urine


Symptoms


  • Anorexia
  • Fever
  • Pain in abdomen
  • Generalized weakness
  • Generalized itching
  • Vomiting
  • Weight loss

Types of Jaundice


1. Pre Hepatic Causes

- the disruption occurs before the bilirubin has been transported from the blood to the liver

  • Sickle cell anemia
  • Hereditary spherocytosis
  • Thalassemia
  • G6PD deficiency
  • Drugs or other toxins
  • Auto immune disorders

2. Intra Hepatic Causes (Hepato Cellular Jaundice)

- the disruption occurs inside the liver

  • Acute or chronic hepatitis
  • Alcoholic hepatitis
  • Cirrhosis of liver
  • Crigler-Najjar syndrome
  • Gilbert’s syndrome
  • Liver cancer
  • Drugs or other toxins
  • Auto immune disorders

3. Post Hepatic Jaundice (Obstructive Jaundice)

- the disruption prevents the bile (and the bilirubin inside it) from draining out of the gallbladder and into the digestive system

  • Common bile duct stones
  • Cancer (gall bladder cancer, pancreatic cancer, CBD cancer)
  • Bile duct strictures
  • Cholangitis
  • Pancreatitis
  • Parasitic infections

Diagnosis


1. Biochemical Investigations - complete blood counts, liver function tests, tumor markers, electrolytes etc

2. Endosonography (EUS)

  • Endoscopic ultrasound (EUS) combines endoscopy and US to provide remarkably detailed images of the pancreas and biliary tree
  • It uses higher frequency ultrasonic waves compared to traditional US and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration
  • Endoscopic ultra sonography overcomes the limitation of evaluation of distal CBD by trans- abdominal sonography. It is very accurate in diagnosing CBD calculi with an overall accuracy of 96% as compared with 63% sensitivity of trans abdominal sonography esp. with small calculi or calculi with non-dilated biliary system
  • It also picks up small resectable pancreato-biliary mass with high sensitivity (93-100%)

3. CT Abdomen

4. MRCP


Complications of jaundice, if not treated


  • Electrolyte imbalances
  • Anemia
  • Bleeding
  • Infection / Sepsis
  • Chronic hepatitis
  • Cancer
  • Liver failure
  • Kidney failure
  • Brain dysfunction
  • Death

Role of Endoscopy


  • Diagnosis can be made and provides information regarding plan of further management
  • Biliary stone disease can be cured in the same sitting
  • Safe, cheap, pain less day care procedure
Anaemia

Anaemia means that you have fewer red blood cells than normal, OR you have less hemoglobin than normal in each red blood cell. In either case, a reduced amount of oxygen is carried around in the bloodstream.

It is extremely prevalent in the Indian population and the incidence is said to be 27% of the adult population and 195 of pediatric group.


Symptoms


  • Tiredness, lethargy
  • Feeling faint, and becoming easily breathless
  • Headaches, a thumping heart (palpitations)
  • Altered taste
  • Ringing in the ears (tinnitus)
  • You may look pale
  • Various other symptoms may develop, depending on the underlying cause of the anaemia

When to seek urgent medical attention


  • Vomiting containing blood
  • Passage of black tarry stool
  • Recurrent fainting episodes with chronic anemia

Causes


  • Pregnancy or childhood growth spurts are times when you need more iron than usual. The amount of iron that you eat during these times may not be enough.
  • Heavy menstrual periods. The amount of iron that you eat may not be enough to replace the amount that you lose with the bleeding each month.
  • Poor absorption of iron may occur with some gut diseases - for example, celiac disease and Crohn's disease.
  • Bleeding from the gut (intestines). Some conditions of the gut can bleed enough to cause anaemia. You may not be aware of losing blood this way. The bleeding may be slow or intermittent, and you can pass blood out with your stools (feces) without noticing.
  • Lack of certain vitamins such as folic acid and vitamin B12.
  • Red blood cell problems such as thalassemia, sickle cell anaemia and other causes of hemolytic anaemia. In these conditions the red cells are fragile and break easily in the bloodstream.
  • Bone marrow problems and leukemia are uncommon, but can cause anaemia.
  • Chronic kidney disease can also cause anaemia.

Investigations


  • Complete blood count
  • Stool for occult blood
  • Peripheral smear examination
  • Other Biochemical tests
  • Upper GI endoscopy
  • Lower GI endoscopy
  • Small bowel Enteroscopy
  • Capsule endoscopy

Treatment


  • Conservative medical management
  • Tailored treatment according to the underlying cause
Carcinoma Pancreas

Pancreatic cancer is the leading cause of cancer deaths in the world and its incidences are rising in India. Pancreatic cancer is the fifth leading cause of death in United States and approximately 30000 pancreatic cancers are diagnosed per year with an incidence rate of 9 cases per 100000 people.

The incidence rate of pancreatic cancer in India is low (0.5 to 2.4 cases per 100000 people). The incidence of pancreatic cancer is higher in urban male populations of western and northern parts of India.


Risk factors


  • Age – 20 times higher risk for individuals older than 50 years
  • Smoking – tobacco smoking contributes to 20 to 30 % of all pancreatic cancers
  • Diabetes mellitus – presence of DM, chronic cirrhosis, pancreatitis and fatty diet has a synergistic effect in development of pancreatic cancer
  • Obesity and lack of physical exercise
  • Occupational hazards
  • Genetic predisposition
  • Miscellaneous

Symptoms


  • Abdominal pain
  • Weight loss
  • Dark colored urine
  • Clay colored stool
  • Generalized itching
  • Nausea/Anorexia
  • Vomiting
  • Early onset diabetes or uncontrolled diabetes

Diagnosis


  • Biochemical investigations and tumor markers
  • EUS and guided FNA
  • CT scan
  • MRI
  • FDG- PET Scan

Treatment


  • Surgery
  • Neoadjuvant and adjuvant chemotherapy
  • Endoscopic palliation
  • Supportive medical care
Hepatitis

Hepatitis means inflammation of the liver. There are a number of things that can cause hepatitis. For example, drinking too much alcohol, various drugs and chemicals, and also several different viruses like hepatitis A, B, C, D, E, G.

What does the liver do?

  • Storing glycogen (fuel for the body) which is made from sugars. When required, glycogen is broken down into glucose which is released into the bloodstream
  • Helping to process fats and proteins from digested food
  • Making proteins that are essential for blood to clot (clotting factors)
  • Processing many medicines which you may take
  • Helping to remove or process alcohol, poisons and toxins from the body
  • Making bile which passes from the liver to the gut down the bile duct. Bile breaks down the fats in food so that they can be absorbed from the bowel

Symptoms


  • Flu-like symptoms. For example, general aches and pains and headaches. (These are the most common symptoms.)
  • Tiredness, feeling sick, sometimes being sick (vomiting) and diarrhea
  • An ache over your liver (the upper part of the right side of your tummy (abdomen) below your ribs)

Diagnosis


  • The doctor performs a liver profile along serological testing of various viruses and a battery of blood tests to rule out other related conditions
  • An ultrasound of the liver is carried out too

Prevention


Hepatitis B, C and D are transmitted via sexual contact, blood transfusion, sharing of needles or vertically to the offspring from the mother.

Prevention of hepatitis A, E, G


  • Raw or inadequately cooked shellfish
  • Raw salads and vegetables that may have been washed in dirty (contaminated) water. (Wash fruits and vegetables in safe water and peel them yourself.)
  • Other foods that may have been grown close to the ground such as strawberries
  • Untreated drinking water, including ice cubes made from untreated water. (Remember also to use only treated or bottled water when brushing your teeth.)
  • Unpasteurized milk, cheese, ice cream and other dairy products
Stones

Stone diseases can be divided in to three categories for better understanding as far as the gastro-intestinal tract is concerned.

1. Gall Bladder Stones
2. Common Bile Duct Stones
3. Pancreatic Stones


Gallbladdder stone 1. Gall Bladder Stones


Gall bladder stone disease is increasing dramatically.

In Japan, prevalence of gall bladder stone disease has been increased to double in last fifty years.

Highest prevalence of gall bladder stone disease was noted among Native American Indians of Arizona, incidence of as high as 73% was noted among females at the age of 30.

In US, the prevalence of gall stone disease is ranging from 5.9 to 21.9 %.

In India, the prevalence of gall bladder stone disease is up to 6.12 %, with Chandigarh and Delhi having the highest number of gall stone disease. The prevalence for development of gall stone disease is increased progressively to reach a peak in the sixth decade.

Symptoms

  • Asymptomatic gall stone disease- patient may not have symptoms as long as 15-20 years. But approximately 20% of them develop symptoms by 15 years
  • Abdominal colicky pain over right upper abdomen
  • Nausea
  • Vomiting
  • Fever
  • Jaundice

Risk factors


  • Age – peak in 40-60 years
  • Gender- females are more prone M:F-1:2
  • Nationality – North India, Scandinavia, Northern Europe, Chile
  • Race/Ethnicity- PIMA Indians of south Africa, native American tribes, Alaskans
  • Family history- high risk in first degree relatives of gall stone patients
  • Obesity
  • Rapid weight loss
  • Multi parity
  • Diabetes mellitus
  • Bowel diseases
  • Total parenteral nutrition
  • Spinal cord injuries

Complications


  • Pancreatitis
  • Fistula between gall bladder wall and bowel
  • Gall bladder perforation
  • Gall stone ileus- gall bladder stone may pass in to the bowel causing obstruction
  • Mirizzi syndrome
  • Emphysematous cholecystitis
  • Gangrene of gall bladder
  • Choledocholithiasis- gall bladder stones may pass in to CBD causing jaundice and infection
  • Porcelain gall bladder
  • Gall bladder carcinoma

Diagnosis


  • Trans abdominal sonography
  • Endoscopic ultra sonography- a novel non invasive modality for diagnosis of pancreato-biliary disorders, which is safe, accurate and less time consuming
  • CT scan
  • MRCP
  • HIDA Scan
  • Biochemical and other investigations

Treatment


  • Medical management- not much role
  • Open cholecystectomy
  • Laparoscopic cholecystectomy
  • EUS guided cholecysto-duodenostomy:- needs further clinical studies and FDA approval

2. Common Bile Duct stones


Bile duct stones are present in approximately 7-12 % of patients with gall bladder stones.

Common bile duct stones may be due to slippage of gall bladder stones in to the CBD or they can form de novo.

Symptoms


  • Abdominal colicky pain
  • Fever
  • Jaundice
  • Nausea
  • Vomiting
  • Disorientation

Risk factors


  • Obesity
  • Low fiber, high calorie, high fat diet
  • Pregnancy
  • Prolonged fasting
  • Sudden weight loss
  • Lack of physical activity

Complications


  • Pancreatitis
  • Mirizzi syndrome
  • Cholangitis

Diagnosis


  • Trans abdominal sonography
  • EUS- a novel non invasive modality for diagnosis of pancreato-biliary disorders, which is safe, accurate and less time consuming
  • CT Abdomen
  • MRCP
  • Biochemical and other investigations

Treatment


  • ERCP- gold standard treatment for management of CBD stone. Minimal invasive, safe and day care procedure in expert’s hand
  • Laparoscopic CBD exploration
  • Open CBD exploration
  • ESWL

3. Pancreatic duct stones


A pancreatic duct stone disease was supposed to be rare disease but the incidence of the disease has been shown to rise recently, especially in western countries.

Pancreatic duct stones are found in 20-60% of the patients with chronic pancreatitis. Pancreatic duct stones usually results from chronic inflammation and altered metabolism.

Symptoms


  • Upper abdominal pain- radiating to back, pain increased after having food
  • Nausea
  • Vomiting
  • Oily, fatty stools
  • Weight loss
  • Indigestion

Risk factors


  • Alcohol
  • Smoking
  • Obesity
  • Sedentary lifestyle
  • Genetic
  • Autoimmune
  • Unknown

Complications


  • Acute pancreatitis
  • Chronic pancreatitis- pancreatic ascites, pseudocyst of pancreas
  • Diabetes
  • Malignancy

Diagnosis


  • EUS- it helps in mapping of pancreas and plan further line of management. It helps in evaluation of ductal and parenchymal disorders
  • MRCP
  • CT Abdomen
  • Trans abdominal sonography
  • Biochemical and other investigations

Treatment


  • Medical management
  • Lifestyle and dietary changes
  • ERCP- gold standard treatment for pancreatic ductal stones which is safe, pain free, less time consuming, minimal invasive and less morbidity compared to surgery
  • ESWL
  • Open surgery
  • Laparoscopic surgery
Ulcers

Peptic ulcer is known as a disease due to hurry, worry and curry.

The term peptic ulcer disease generally refers to spectrum of disorders that includes gastric ulcer, pyloric ulcer, and duodenal ulcer and post operative ulcers at or near the site of surgical anastomosis.

Peptic ulcer is a term used to describe, “Any localized erosion of the mucosal lining of the portion of the alimentary tract that come in contact with the gastric juice.

Epidemiology - Scenario in India
Peptic ulcer occurs in approximately 10% of the population. Higher incidence of the peptic ulcer cases were observed among people in between the age of 30 – 60 years.

Gastric ulcers are more likely to occur during the fifth and sixth decades of life. Duodenal ulcers are more commonly occur during the fourth and fifth decades for men.

The prevalence in children is around 0.5% in industrialized nations.

Approximately 25 million Indians are suffering from peptic ulcer disease at some point in their life time. Duodenal ulcers are 5 to 10 times more common than gastric ulcers. The incidence for duodenal ulcer is 30 to 60 years. The male and female ratio is 3:1. The incidence of gastric ulcer is usually 50 and over. It affect male and female in the ratio of 2:1. Each year there are 500,000 to 850,000 new cases of peptic ulcer disease and more than 1 million ulcer related hospitalizations.

An endoscopic and epidemiological study was conducted to determine the prevalence of peptic ulcer disease in the general population by Institute of Medical Sciences, India. The point prevalence of peptic ulcer was 4.72% and the life time prevalence was 11.22%. The prevalence of peptic ulcer increased with age, with a peak prevalence of 28.8% in the fifth decade of life. Peptic ulcer was not related to socio economic status.

Risk factors/causes


  • Excessive use of pain killer drugs
  • Excessive drinking of alcohol
  • Smoking or tobacco chewing
  • Smoking or tobacco chewing
  • Excessive tea or coffee intake
  • Binge diet
  • H.Pylori infection
  • Excessive acid production by stomach tumors
  • Serious illness
  • Radiation therapy to that area
  • Physical and emotional stress

Symptoms


  • Burning like sensation or pain in the middle or upper abdomen
  • Abdominal bloating sensation
  • Nausea
  • Vomiting
  • Reflux of food or acid in the mouth
  • Bad taste in mouth
  • Black colored stools
  • Weight loss

Red Flag Sign - When to Seek Urgent Medical Care


  • Vomiting of blood or dark coffee ground color
  • Passing black tar like stools
  • Significant weight loss

Complications, if not treated


  • Bleeding
  • Perforation
  • Gastric outlet obstruction
  • Malignancy

Diagnosis


  • Upper GI endoscopy and biopsy
  • Urea breath test for detection of H.Pylori
  • Stool antigen test for H.Pylori
  • Blood test to look for antibodies to H.Pylori
  • 24 hour PH test
  • High resolution manometry

Prevention


  • Dietary modifications
  • Life style modifications

Treatment


  • Life style and dietary management
  • Medications
  • Surgery