A Family Doctor's Tale - HYPOCALCEMIA

DOC I HAVE HYPOCALCEMIA

Hypocalcemia is defined as low Calcium (less than 8.4 mg per liter) in the blood.

Normal blood Calcium varies from 8.4 to 10.4 mg per liter.

Calcium and phosphate are interrelated both regulated by the parathyroid hormones and Vitamin D which control the calcium and phosphate exchange between the blood and three important systems in the body:
1.skeletal
2.gastrointestinal
3.renal

Parathyroid hormones acts mainly on the bones and kidney to raise the blood calcium and increase the phosphate excretion.

Vitamin D increases the intestinal absorption of calcium and phosphate.

Hypocalcemia or low calcium level in the blood is caused by:
1.Hypoparathyroidism from surgical removal of parathyroid gland during thyroidectomy

2.Idiopathic hypoparathyroidism from genetic causes, sometimes unknown causes

3.Malabsorption of calcium, Vitamin D or phosphates from diet.

4.Hypoalbuminemia

5.Chronic renal failure

5.Osteomalacia -lack of mineralization of the bone matrix

6.Rickets - abnormal condition of the bones caused by low Vitamin D

7. Hyperventilation- calcium is bonded to the carbonate in the blood. If the carbon dioxide level in the blood is low, then less calcium is present because the carbonate in the blood is low.

Symptoms of hypocalcemia:
1.neuromuscular hyperexcitabilty resulting  in tetany(a cramp condition of the index finger )

2.convulsions

3.stridor -due to tightening of the muscle of vocal cord

4.smooth muscles tightening

5.diarrhea

Signs:
1.Trousseau's sign - Raising the blood pressure to 200 systolic using the blood pressure cuff on the upper arm can cause the typical sign of tetany or obstretician's finger in hypocalcemia


2.Chvostek's sign - tapping the seventh nerve on the same side of the jaw as the tetany sign can cause the finger to jerk confirming hypocalcemia


Diagnosis:
1.Plasma Calcium levels

2.Blood phosphate level

3.Total serum protein levels
low serum calcium in the presence of low albumin allows a higher free cacium concentration making the patient to be normocalcemic. (normal  blood cacium)

4.Bone density test

Treatment:
1.Intravenous calcium carbonate under cardiac monitoring as excessive calcium may affect the heart

2.oral Calcium supplements is given in most cases as a long term treatment usually with improvement of blood Calcium level

3.Large doses of Vitamin D may be necessary in some cases.

4.Treat underlying cause.

5.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate electrolyte replacement after exercise
also after vomiting and diarrhea

A Family Doctor's Tale - HYPERCALCEMIA

DOC I HAVE HYPERCALCEMIA

Hypercalcemia is defined as high calcium(above 10.4 md per liter) in the blood.

Normal blood Calcium varies from 8.4 to 10.4 mg per liter.

Calcium and phosphate are interrelated both regulated by the parathyroid hormones and Vitamin D which control the calcium and phosphate exchange between the blood and three important systems in the body:
1.skeletal
2.gastrointestinal
3.renal

Parathyroid hormones acts mainly on the bones and kidney to raise the blood calcium and increase the phosphate excretion.

Vitamin D increases the intestinal absorption of calcium and phosphate.

Hypercalcemia occurs with high calcium due to:
1.High parathyroid hormones due to parathyoid adenomas

2.Vitamin D excess

3.Various malignancies including myeloma and leukemia.

4.breast tumors and metastases

5.sarcoidosis

Symptoms of Hypercalcemia:
1.weakness

2.lethargy

3.intractable nausea and vomiting

4.dehydration

5.constipation

6.coma

7.cardiac arrthymia

8.calcification of joint or skin

Diagnosis:
1.Plasma calcium and phosphate levels

2.Blood sodium bicarbonate and gases

3.Blood albumin and proteins

4.Joint Xrays in cases of joint calcification

Complications:
1.Calcification of gouty trophi

2.renal stones

3.Cacific tendonitis

4.Myositis ossificans

5.chondrocalcinosis

6.phosphate arthropathy

Treatment:
Acute hypercalcemia is a medical emergency because of its effect on the heart rhythm.
1.Immediate treatment of intravenous isotonic saline and

2.a powerful diuretic such as frusemide to induce excess calcium to pass out through the urine

3.Phosphate intravenously or orally can also be effective to reduce the calcium from the blood although it may cause diarrhea

4.Corticosteroids are also effective in reducing calcium blood levels.

5.Treat underlying cause.

6.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate water replacement after exercise
also after vomiting and diarrhea

A Simple guide to Scarlet Fever

A Simple guide to Scarlet Fever
-----------------------------------------------

What is Scarlet Fever?
------------------------------------
Scarlet Fever is an acute febrile infectious disease of the upper respiratory tract caused by the erythrogenic toxin associated with the bacillus Group A Streptococcus(GAS).

How is Scarlet Fever transmitted?
-----------------------------------------------


Scarlet Fever is transmitted through the air through
1.droplets from the infected tonsillar or pharyngeal area of infected patients.
2.infected articles or food,
3.infected wounds or
4.infected umbilical stumps of neonates 

It is highly infectious, being communicable from 24 hours before onset of symptoms to 2 to 3 weeks after onset of symptoms.

Asymptomatic carriers can also spread the disease.

Incubation period is 2 - 5 days.

The organism enters the blood from the throat and produce an erythrogenic toxin which causes  the symptoms of fever and rash.

The rash is the main symptom which gives rise to the scarlet appearance, hence the name Scarlet Fever.

The infections occur in persons of all ages but peak incidence is 5- 15 years. Males are affected equally as females.

Usually 1 attack will confer permanent immunity to the erythrogenic toxin of GAS streptococcus.

What are the Signs and Symptoms of Scarlet Fever ?
------------------------------------------------------------------------

Symptoms start off with:
1. sudden onset of headache

2. high fever 39-40 degrees centigrade

3. chills and rigors

4. sore throat(infected tonsils)

5. vomiting

6. cervical lymphadenopathy

Subsequent symptoms follows:
1.punctate erythrematous rash appearing 12 to 24 hours later after the fever, starting from the neck and chest then spreads rapidly.
The face is not affected.

2.Facial flushing and pale area around the mouth

3.Dark red lines along skin creases (Pastia's lines)

4.Rash blanches when pressed

5.Tongue coated with white fur with occasional red papillae (white strawberry tongue) The white fur peels on the third day and becomes red by the fourth day (red strawberry tongue)

How to diagnose Scarlet Fever?
-------------------------------------------------------------
1.Symptoms of fever and rash
2.ESR raised very high somtimes > 80
3.moderate leucytosis
4.Throat swab for culture and sensitivity

What are the complications of Scarlet Fever?
----------------------------------------------------------------

1.otitis media

2.rheumatic fever

3.glomerulonephritis

4.henoch-schonlein purpura

What is the Treatment of Scarlet Fever?
------------------------------------------------------------

Isolation in hospital may be needed.
1.Antibiotics (penicillin or amoxicillin) are used in the treatment of Scarlet Fever. Treatment is for at least 10 days.
Alternatives are cephalosporins such as cephelexin in penicillin sensitive patients
2.Paracetamol is given for fever and pain
3.Bed rest , fluids and general supportive care

What is the Prevention for Scarlet Fever?
---------------------------------------------------

Avoiding infected patients
Recently there are new cases of Scarlet Fever in Hong Kong.

What is the Prognosis of Scarlet Fever?
-------------------------------------------------


In fact after the introduction of antibiotics, there is very few cases of Scarlet Fever.
Early therapy with antibiotics produce excellent recovery
In rare cases complications such as rheumatic fever and glomerulonephritis can occur

A Family Doctor's Tale - HYPERNATREMIA

DOC I HAVE HYPERNATREMIA

Hypernatremia is defined as high Sodium in the blood.

Normal blood Sodium varies from 136 to 145 mmol per liter.

Extracellular Sodium level represents only 2 per cent of the total body Sodium.

Sodium is a major determinent of intracellular volume of cells and intracellular osmolarity.

It is a also an important cofactor in many metabolic processes.

The resting membrane potential and excitable tissues like nerves is mainly determined by ratio of intracellular to extracellular Sodium concentrations.

Plasma and extracellular Sodium levels are influenced by many factors particularly acid based balance. Acidosis moves Sodium out of cells while alkalosis shifts Sodium into cells.

Hypernatremia occurs with high sodium due to:
1.dehydration from insufficient water intake or excess water loss

2.impaired renal function cause retention of sodium

3.cardiac disease can cause retention of salt

4.excess intake of salt

Symptoms of Hypernatremia:
1.edema

2.peripheral muscles tetany

Diagnosis:
1.Plasma Sodium levels

2.Blood sodium bicarbonate and gases

3.Urinary electrolytes

Treatment:
1.More intake of water may reduce concentration of sodium

2.diuretic to induce excess sodium to pass out through the urine

3.Infusion of sodium bicarbonate to induce alkalosis

4.Infusion of calcium bicarbonate to induce alkalosis

4.administer Sodium binding resins by mouth

5.Treat underlying cause.

6.Frequent monitoring of progress by blood studies

7.hemodialysis

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate water replacement after exercise
also after vomiting and diarrhea

A Family Doctor's Tale - HYPONATREMIA

DOC I HAVE HYPONATREMIA

Hyponatremia is defined as low Sodium in the blood.

Normal blood Sodium varies from 136 to 145 mmol per liter.

Extracellular Sodium level represents only 2 per cent of the total body Sodium.

Sodium is a major determinant of intracellular volume of cells and intracellular osmolarity.
It is a also an important cofactor in many metabolic processes.
The resting membrane potential and excitable tissues like nerves is mainly determined by ratio of intracellular to extracellular Sodium concentrations.

Plasma and extracellular Sodium levels are influenced by many factors particularly acid based balance. Acidosis moves Sodium out of cells while alkalosis shifts Sodium into cells.

Hyponatremia occurs with loss of salt through:
1.gastrointestinal -vomiting and diarrhea

2.urinary loss especially following use of Sodium wasting diuretics

3.sweating

4.fistula

5.diabetes mellitus.

Symptoms of hyponatremia:
1.lethargy

2.generalized fatigue

3.muscle weakness

4.reduced urination

Diagnosis:
1.Plasma Sodium levels

2.Blood sodium bicarbonate and gases

3.Urinary electrolytes

Treatment:
1.oral Sodium chloride (or salt) is given in most cases with improvement of blood Sodium level

2.Intravenous Sodium chloride dextrose solutionis given in emergency cases.

3.Bicarbonate or lactate infusion may help correct acid base disorders depending on underlying cause.

4.Treat underlying cause.

5.Frequent monitoring of progress by blood studies

Prognosis:
is good in most cases depending on rapidity of treatment and cause.

Prevention:
adequate electrolyte replacement after exercise
also after vomiting and diarrhea

A Family Doctor's Tale - DIARRHEA

DOC I HAVE DIARRHEA

Diarrhea is a symptom defined as an increase in the volume, water content and frequency of bowel movements.

Diarrhea is a symptom of many gastrointestinal disorders:
1.Infections:
Bacterial infections such as:
a.Shigella
b.Salmonella and typhoid
c.cholera

Viral infections such as:
a,enterovirus
b.rotavirus

Protozoan infections such as:
a.amoebic
b.giardia

2.Toxins from bacteria in contaminated food:
a.E.coli food poisoning (enterotoxins)
b.staphaloccal food poisoning (preformed toxins)

3.Antibiotic usage:
pseudomembraous enterocolitis

4.Food Intolerance
a.Lactose or sugar intolerance
b.Gluten sensitive enteropathy:
celiac disease, nontropical sprue

5.Inflammatory diseases of the intestine:
a.crohn's disease or regional ileitis
b.ulcerative colitis

6.Malabsorption syndromes
a.malabsorption of bile acids
b.pancreatic steatorrhea
c.ileal resection

7.Cancers:
a.colon
b.rectal cancers

8.Tumors especially hormonal producing tumors:
a,gastrinoma
b.Zollinger-Ellison syndrome
c.glucaglonoma
d.carcinoid tumors

9.Drug induced:
a.excessive use of laxatives
b.magnesium antacids which absorbs water into intestine
c.stimulant cathartics

10.Rapid intestinal movement:
a.Irritable bowel syndrome
b.resection of bowels in tumors or fistula
c.vagotomy
d.other surgery of intestine
rhea with blood and mucus

Diarrhea is investigated by:
1.full investigation of the possible underlying causes

2.Macroscopic and microscopic examination of the stools:
e.g rice water is typical of cholera

3.culture and sensitivity to antibiotic of the stools

4.Full blood count and electrolytes

Treatment of Diarrhea is by:

1.Because of the excessive fluid loss, correction of fluid and electrolyte balance is the most important part of treatment.

Prompt treatment may be needed to prevent dehydration which is the loss of fluids from the body. Important salts or minerals, known as electrolytes, can also be lost with the fluids. Dehydration can be caused by diarrhea, excessive urination, excessive sweating, or by not drinking enough fluids because of nausea, difficulty swallowing, or loss of appetite.

The symptoms of dehydration are
excessive thirst
dry mouth
little or no urine or dark yellow urine
sunken eyes
severe weakness or lethargy
dizziness or light headedness

Mild dehydration can be treated by drinking liquids.

Severe dehydration may require intravenous fluids and hospitalization.

Untreated severe dehydration can be life threatening especially in babies, young children and the elderly.

2.Specific treatment if available for underling conditions eg.antibiotic the choice of which depends on the sensitivity of bacteria to the antibiotic.

3.Relief of symptoms include an antispasmodic drug to stop abdominal cramps, medicine to harden the stools such as kaolin and slow down the intestinal movement (lomotil or loperamide).

The following steps may help relieve the symptoms of Diarrhea.
1.Allow your gastrointestinal tract to settle by not eating for a few hours.
2.Sip small amounts of clear liquids or suck on ice chips if vomiting is still a problem.
3.Give infants and children oral rehydration solutions to replace fluids and lost electrolytes. 4.Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.
5.Avoid dairy products, caffeine, and alcohol until recovery is complete.
6.Get plenty of rest.

Prognosis of diarrhea depends on the cause:

Usual outcome of acute diarrhea is excellent if treated early.

For chronic diarrhea, the underlying cause must be treated.

Outcome is usually excellent with appropriate treatment.

Prevention of Infections causing Diarrhea is by:
You can avoid infection by:
1.washing your hands thoroughly for 20 seconds after using the bathroom or changing diapers


2.washing your hands thoroughly for 20 seconds before eating


3.disinfecting contaminated surfaces such as counter tops and baby changing stations


4.Avoid eating or drinking foods or liquids that might be contaminated

A Family Doctor's Tale - SHIGELLA DYSENTERY

DOC I HAVE SHIGELLA DYSENTERY

Shigella Dysentery is an acute invasive infection  of the lining of the intestines caused by a bacteria of the genus Shigella resulting in leakage of fluid from the cell into the intestine(diarrhea), abdominal pain and vomiting.

The causes of Shigella Dysentery are:
4 subspecies of Shigella has been recognised as causative agents:

1.Group A :Shigella dysenteriae

2.Group B :Shigella flexneri

3.Group C :Shigella boydii

4.Group D :Shigella sonnei (most common in North America, Europe and Japan

Humans are the only known reservoir of Shigella infection.

Transnission occurs most often by close personal contact through hands or soiled clothing or fecal-oral contamination.

The bacteria pass through the gastric acid barrier relatively easily and proliferate in lower ileum and colon.

Multiplication of bacteria occurs within the epithelial cells followed by micro-abscesses on the villi of intestine.

Stools can contain red blood cells and white blood cells.

There may blood in the stools.

Since the infection is superficial, bacteremia is rare and perforation of the colon seldom occurs.

The symptoms of Shigella Dysentery are:
Incubation period is one to two days.

In the early phases lasting one to three days, the main symptoms of Shigella Dysentery are:
1. watery diarrhea with blood and mucus
2. cramping abdominal pain
3. fever up to 40 degrees centigrade
4. headache and bodyaches
5. serious fluid loss especially in children
6. loss of appetite and energy

In the later stages:
1.bowel movements quantity decreases but still contain blood and mucus
2.fever has subsided
3.decreased appetite and energy
4.weight loss
5.convulsions may occur in children

Shigella Dysentery can be transmitted by:
Shigella Dysentery can be highly contagious. The germs are commonly transmitted by people with unwashed hands.

People can get the germs through close contact with infected individuals by sharing their food, drink, or eating utensils, or by eating food or drinking beverages that are contaminated with the germs.

Doctors generally diagnose Shigella Dysentery based on

1.the symptoms and a physical examination.

2.stool sample to test for shigella and microscopic examination.

Microscopic examination shows the presence of red blood cells and polymorphs white blood cells.

Treatment of Shigella Dysentery is by:

1.Because of the excessive fluid loss, correction of fluid and electrolyte balance is the most important part of treatment.

Prompt treatment may be needed to prevent dehydration which is the loss of fluids from the body. Important salts or minerals, known as electrolytes, can also be lost with the fluids. Dehydration can be caused by diarrhea, excessive urination, excessive sweating, or by not drinking enough fluids because of nausea, difficulty swallowing, or loss of appetite.

The symptoms of dehydration are
excessive thirst
dry mouth
little or no urine or dark yellow urine
sunken eyes
severe weakness or lethargy
dizziness or lightheadedness

Mild dehydration can be treated by drinking liquids.

Severe dehydration may require intravenous fluids and hospitalization.

Untreated severe dehydration can be life threatening especially in babies, young children and the elderly.

2.Antibiotics is necessary,the choice of which depends on the sensitivity of bacteria to the antibiotic.

3.Relief of symptoms include an antispasmodic drug to stop abdominal cramps, medicine to harden the stools such as kaolin and slow down the intestinal movement (lomotil or loperamide).

The following steps may help relieve the symptoms of Shigella Dysentery
1.Allow your gastrointestinal tract to settle by not eating for a few hours.


2.Sip small amounts of clear liquids or suck on ice chips if vomiting is still a problem.


3.Give infants and children oral rehydration solutions to replace fluids and lost electrolytes.

4.Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.


5.Avoid dairy products, caffeine, and alcohol until recovery is complete.


6.Get plenty of rest.

Prognosis of Shigella Dysentery is:
50% of Shigella dysentery develop full blown symptoms as above

25% will only have watery diarrhea

Symptoms usually improve within one to 2 days after the onset of treatment.

Outcome is usually excellent with appropriate treatment.

Prevention of Shigella Dysentery is by:
You can avoid infection by:
1.washing your hands thoroughly for 20 seconds after using the bathroom or changing diapers
2.washing your hands thoroughly for 20 seconds before eating
3.disinfecting contaminated surfaces such as counter tops and baby changing stations
4.Avoid eating or drinking foods or liquids that might be contaminated

A Family Doctor's Tale - MEGACOLON

DOC I HAVE MEGACOLON

Megacolon is the dilatation and often hypertrophy of part or all the colon associated with constipation.

There is predominance of occurrence of 8 males to 1 female.

There is a familial history.

Two main causes  of Megacolon are

1.Congenital(also known as Hirsprung Disease)

The Congenital Megacolon occur in newborns due to the absence of autonomic ganglia from the distal segment of the colonic wall, varying in length(about 1 to 2 cm from rectosigmoid junction to entire colon).

Aganglionic colon provides a functional block to defecation, thus the colon proximal to the affected portion becomes grossly dilated and hypertrophied.

2.Acquired

a.Sliding megacolon:

The acquired idiopathic form is a functional disturbance of the colon in older children or adults resulting from persistent failure or inadequate rectal evacuation.

b.Paraesopphageal :

when the gastroesophageal junction is below the the diaphragm and part of the stomach herniates upwards along the esophagus.

The most common symptoms  of Megacolon are :

Congenital:

1.gross abdominal distension in severe cases

2.Constipation alternating with diarrhea due to bacterial overgrowth in milder cases

3.Respiratory distress may be present in infants due the pressure of the abdomen on the lung space.

4.weight loss

5.Rectum is usually empty on examination

Acquired:

1.Onset is slower with constipation

2.gross abdominal distension

3.Rectal examination shows a lax sphincter and full rectum

The Diagnosis of Megacolon is:

Megacolon is diagnosed through one or more medical tests:

Congenital:

1.lower gastrointestinal endoscopy.

Colonoscopy show presence of narrowed distal segment and transition to dilated part of colon.

2.colon biopsy showed neuronal lesion.

3.Rectosphincteric manometric studies show absence of anal sphincter response

Acquired:

1.colonoscopy showed gross rectal dilatation but no narrowed segment

2.colonic biopsy is normal

The Treatment of Megacolon is by:

The main treatment is :

Congenital:

1.colostomy may be required as a life saving measure

2.This is followed by later surgical resection of short segment or longer segment of the colon

Acquired:

1.Evacuation of impacted stools

2.suppositories or microenema to clear rectal feces daily

3.mild laxatives to help induce passing of stools

4.Retraining of toilet habits

The Complications of untreated Megacolon are:

1.dehydration in infants during severe gastroenteritis episodes

2.obstruction of the intestines

3.toxic megacolon

Prognosis of Megacolon is :

1. good to excellent in acquired form if treated medically

2.surgery is needed in the congenital form

Prevention in acquired megacolon is to

1.have good toilet and bowel habits .

2.Avoid constipation by taking more fruits and vegetables and fibre.

3.Enough physical exercise to help the intestine move easier.

 

A Family Doctor's Tale - PSEUDOMEMBRANOUS ENTEROCOLITIS

DOC I HAVE PSEUDOMEMBRANOUS ENTEROCOLITIS

Pseudomembranous Enterocolitis is an inflammatory disease of the small and large intestine often associated with antibiotic use and with serious illnesses requiring chemotherapy or postoperative conditions.

The causes of Pseudomembranous Enterocolitis are:

The illness is believed to be due to the eradication of normal bowel flora from excessive use of antibiotics resulting in exposure to Clostridium difficile and its toxins.

The involved bowel mucosa is friable(thin) and has yellow green plagues which coalesce and form a thin membrane on the mucous lining.

The membrane consists of fibrin, mucus, and inflammatory cells.

The submucosa is edematous and necrotic in the advanced stage.

Besides clostridium, staphalococcus aureus has been isolated in cases of Pseudomembranous Enterocolitis.

The  symptoms and signs of Pseudomembranous Enterocolitis are:

The disease may be suspected from the clinical picture of abdominal discomfort especially a history of prolonged antibiotic usage.
The main symptoms of Pseudomembranous Enterocolitis are:
1. watery diarrhea with blood,pus and mucus

2. cramping abdominal pain and distension

3. fever up to 39 degrees centigrade

4. headache and bodyaches

5. serious fluid loss and dehydration

6. metabolic acidosis

Signs:
Typical pseudomembrane seen on sigmoidoscopy</p>

The diagnosis of Pseudomembranous Enterocolitis  is made by  :

1.Doctors generally diagnose Pseudomembranous Enterocolitis based on the symptoms and history

3.typical pseudomembrane seen on sigmoidoscopy

The treatment of Pseudomembranous Enterocolitis is:

1.Because of the excessive fluid loss, correction of fluid and electrolyte balance is the most important part of treatment.

Prompt treatment may be needed to prevent dehydration which is the loss of fluids from the body. Important salts or minerals, known as electrolytes, can also be lost with the fluids. Dehydration can be caused by diarrhea, excessive urination, excessive sweating, or by not drinking enough fluids because of nausea, difficulty swallowing, or loss of appetite.

The symptoms of dehydration are
excessive thirst
dry mouth
little or no urine or dark yellow urine
sunken eyes
severe weakness or lethargy
dizziness or lightheadedness

Mild dehydration can be treated by drinking liquids.

Severe dehydration may require intravenous fluids and hospitalization.

Untreated severe dehydration can be life threatening especially in babies, young children and the elderly.

2.Stop all antibiotics if still administered

3.Relief of symptoms include an antispasmodic drug to stop abdominal cramps, medicine to harden the stools such as kaolin and slow down the intestinal movement (lomotil or loperamide).

4.Get plenty of rest.

5.surgery may be necessary if perforation of intestine has occurred.

Prognosis of  Pseudomembranous Enterocolitis:

Outcome is usually excellent with early diagnosis and appropriate treatment.

Prevention of Pseudomembranous Enterocolitis is by:

No prolonged antibiotics.

 

 

 

A Family Doctor's Tale - HIATUS HERNIA

DOC I HAVE HIATUS HERNIA

Hiatus Hernia is a protrusion of part of the stomach through the diaphragmatic hiatus (or hole) into the chest.

Two main causes are
1.Congenital
The Hiatus Hernia occur in newborns as a result of the diaphragm to fuse.
There is a familial history.

2.Acquired
a.Sliding -most common type - occurs when the gastroesophageal junction and part of the stomach above the diaphragm may be associated with a short esophagus secondary to esophagitis and stricture of the esophagus from scarring(due to gastric acid)

b.Paraesopphageal :when the gastroesophageal junction is below the the diaphragm and part of the stomach herniates upwards along the esophagus.

Vomiting of the retained food in the part of the stomach stuck in the diaphragm is a natural progression of the condition.

The Symptoms of Hiatus Hernia are:

Most hiatus hernia are asymptomatic.
The most common symptoms are those of esophageal reflux:
1.heartburn aggravated by bending down, lying down, smoking, alcohol, and heavy meals

2.belching, abdominal bloating,

3.acid reflux to the throat

4.nausea, and vomiting of ingested food

5.fullness and pain after eating may be caused by mechanical obstruction of the pouch of the stomach in paraesophagel type of hiatus hernia

6.Respiratory distress may be present in infants due the pressure of the stomach on the lung space.

7.weight loss

8.bleeding

Hiatus Hernia is diagnosed through one or more medical tests:

1.Upper gastrointestinal endoscopy.
The doctor uses an esophagoscope, a thin tube containing a tiny camera, through your mouth  and down into your stomach to look at the stomach lining for erosions and narrowing of the passage of the upper part of the stomach and esophagus

2.MRI of the upper abdomen usually shows the presence of excess stomach content in the lung area above the diaphragm
and presence of hiatus hernia.

The Treatment of Hiatus Hernia is:
The main treatment is usually medical especially for sliding hernia.

1.correction of fluid and electrolyte deficit by intravenous infusion of saline and glucose

2.Antacids:to reduce stomach acid from gastric reflux and thereby help relieve symptoms and promote healing. (Stomach acid irritates the inflamed tissue in the esophagus and the upper stomach.)

3.H2 Antagonist: to reduce to production of acidic gastric juice.(cimetidine, ranididine,omeprazole, Nexium etc)

4. Antispasmodics: anticholinergic drugs like buscopan.librax reduce the spasm in the stomach and esophagus

Surgery:
The surgery involves repair of the diaphragmatic hernia and the return of the stomach to below the diaphragm in the paraesophageal cases of hiatus hernia.

1.Surgical treatment may be necessary in cases with persistant esophageal reflux and severe esophagitis.

2.Paraesophageal hernias are less amenable to medical treatment and often require surgical treatment.

3.Emergency surgery is required in cases of strangulation of the esophagus, esophageal obstruction or perforation.

The Complications of untreated Hiatus Hernia are:
1.strangulation of esophagus

2.obstruction of the esophagus

3.perforated esophagus

Prognosis of Hiatus Hernia is :
1. good to excellent if treated surgically to repair the hernia.

2.medical treatment may work but recurrence rate is high.

A Family Doctor's Tale - PYLORIC STENOSIS

DOC I HAVE PYLORIC STENOSIS

Pyloric Stenosis is a stricture at the lower end of the stomach (pylorus)which can obstruct outflow of gastric content to the duodenum.

Two main causes of Pyloric Stenosis are :
1.Congenital
The pyloric stenosis occur in 0.2 per cent of live births with a preponderance ratio of 4 males to 1 female.
There is a familial history.

2.Acquired
a.Scarring - gastric juice burns into the protective lining of the stomach resulting in gastritis or peptic ulcer. The resultant scarring of the stomach lining at the pylorus may cause narrowing or stenosis of the outlet obstructing the outflow of gastric content. Scarring can occur in 5-10 per cent of peptic ulcers especially duodenal ulcers.

b.Spasm of the pyloric muscles due to gastritis or peptic ulcer can also reduce the opening at the outlet of the stomach.

c.mechanical obstruction from a tumor of the stomach

Early cases of pyloric stenosis can be reversed more easily.

Later cases results in gastris dilatation with retention of gastric contents due to obstruction.

Vomiting of the retained food in the stomach is a natural progression of the condition.

The most common symptoms and signs of Pyloric Stenosis are :
1.upper abdominal upset or pain.

2.belching, abdominal bloating, aversion to food

3.nausea, and vomiting of ingested food

4.Protracted copious vomiting due to obstruction at the outflow of the stomach

Signs:
5.gastric splash can be felt and heard on examination

6.weight loss

7.dehydration

Pyloric Stenosis is diagnosed through one or more medical tests:
1.Upper gastrointestinal endoscopy.
In the case of pyloric stenosis, the gastric content (usually large amount) has to be removed by aspiration through a stomach tube 3 hours before any procedure can be done.

The doctor eases an gastroscope, a thin tube containing a tiny camera, through your mouth  and down into your stomach to look at the stomach lining for polyps or tumors blocking the pylorus. If there is no tumor, there may evidence of gastritis or peptic ulcer and narrowing of the passage of the pylorus from scarring or spasm.

2.MRI of the upper abdomen usually shows the presence of excess stomach content and may show evidence of any benign tumor or cancer.

3.Blood tests for electrolytes in cases of dehydration

The main treatment of Pyloric Stenosis is usually
1.correction of fluid and electrolyte deficit by intravenous infusion of saline and glucose

2.removal of stomach content through a nasogastric tube to eliminate distension of stomach and restore tone of stomach muscles

Medications:
Treatment usually involves taking drugs
1.Antacids:to reduce stomach acid and thereby help relieve symptoms and promote healing. (Stomach acid irritates the inflamed tissue in the stomach.)
2.H2 Antagonist: to reduce to production of acidic gastric juice.(cimetidine, ranididine,omeprazole, Nexium etc)
3. Antispasmodics: anticholinergic drugs like buscopan.librax reduce the spasm in the stomach and duodenum
4.If the peptic ulceris caused by an infection, that problem may be treated with antibiotics to clear up H. pylori infection.

Surgery:
Surgical treatment may be necessary to remove any tumor or cancerous groth causing blockage.

Any stricture in the pylorus may be dilated or removed for the food to empty out easily to the duodenum.

The Complications of untreated Pyloric Stenosis are

1.dehydration

2.anorexia and loss of weight

3.perforated stomach and peritonitis

Prognosis of Pyloric Stenosis is :
good to excellent if treated early except for cases of cancer of the stomach.

Prevention of Pyloric Stenosis:
avoid gastritis and peptic ulcers

A Family Doctor's Tale - PEPTIC ULCER

DOC I HAVE PEPTIC ULCER

Peptic ulcer is a ulcer or hole in the lining of the stomach or duodenum.

Two main causes of Peptic ulcer are
1..helicobacter pylori infection - this bacteria damages the protective lining of the stomach making the underlying stomach tissue more vulnerable to the acidic gastric juice.

2.excessive production of acidic gastric juice
Excessive production of acidic gastric juice burns into the protective lining of the stomach and cause inflammation of the underlying stomach tissue.

The causes of excessive production of acidic gastric juice are:
1. Most common is stress and anxiety which automatically increase the production of the acid as a result of sympatheic nervous reaction


2.hereditary- some gastric patient has family history of gastric problem. Blood group O tends to have more gastitis while Blood group A has a tendency towards stomach cancer.


3.irregular meals tend to cause more acidic gastric juice to form at regular meal time.


4.alcohol and smoking has been associated with increased acid formation


5.Drugs: prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen,

Most gastric ulcers occur on the lining of the lesser curvature of the stomach while dudenal ulcers occur on the first part of the duodenum

What are the Symptoms of Peptic ulcer?
-----------------------------------------
The most common symptoms are
1.upper abdominal upset or pain.

2. belching, abdominal bloating,

3.nausea, and vomiting especially if there is obstruction as pyloric stenosis

4.indigestion or of burning in the upper abdomen or in the chest(heart burn).

5. Blood in your vomit or black stools may be a sign of bleeding in the stomach, which may indicate a serious problem requiring immediate medical attention.

Signs:
6.epigastric tenderness on examination

7.anorexia

6.loss of weight due to poor digestion and absorption

Peptic ulcer is diagnosed through one or more medical tests:
1.Upper gastrointestinal endoscopy.

The doctor eases an gastroscope, a thin tube containing a tiny camera, through the mouth  and down into the stomach to look at the stomach lining.
The doctor will check for inflammation (gastritis) and ulcers and may remove a tiny sample of tissue for tests(biopsy). The biopsy will detect how bad is the inflammation or whether there are underlying cancer cells.
In additional if any polyps (benign swelling of the lining of the stomach) are detected, they are removed at the same time and sent for biopsy.

2.Blood test. The doctor may check your blood for any evidence of H.pylori infection and the red blood cell count to check for anemia (not enough iron in the red blood cells.
Anemia can be caused by bleeding from the stomach.

3.Urea breath test can also determine whether there is H.pylori infection

4.Stool test. This test checks for the presence of blood in the stool, a sign of bleeding. Stool test may also be used to detect the presence of H. pylori in the digestive tract.

The main treatment of Peptic ulcer is usually
1.reduce stress

2.reorganisation of work in such a way as to be able to handle the pressure of work better as well as to have regular meals

3.Control of diet - avoid hard foods such as peanuts , tough meat, spicy food, cold food, black coffee, strong tea,citrus fruits and their juices,carbonated beverages, deep fried or oily food.

4. Take more frequent and smaller meals.

5. Avoid alcohol and smoking

6. Avoid drugs such as aspirin, painkillers,steroids which may irritate your stomach and cause increase in acid production

Medications:
Treatment usually involves taking drugs
1.Antacids:to reduce stomach acid and thereby help relieve symptoms and promote healing. (Stomach acid irritates the inflamed tissue in the stomach.)

2.H2 Antagonist: to reduce to production of acidic gastric juice.(cimetidine, ranididine,omeprazole, Nexium etc)

3. Antispasmodics: anticholinergic drugs like buscopan.librax reduce the spasm in the stomach and dudenum

4.If your Peptic ulcer is caused by an infection, antibiotics are given  to clear up H. pylori infection. Once the underlying problem disappears, the Peptic ulcer usually does too.

Surgery:
Surgical treatment is the last resort if the above treatment do not work.

Resection of the ulcers and vagotomy(cutting of the vagal nerve to reduce acid secretion) may be necessary in rare cases.

The Complications of untreated Peptic ulcer are:

1.bleeding

2.pyloric stenosis

3.perforated stomach and peritonitis

Prognosis of Peptic ulcer:
Healing occurs with 6 to 12 weeks .

However recurrence is common.

A Family Doctor's Tale -DYSPEPSIA

DOC I HAVE DYSPEPSIA

Dyspepsia is a symptom of discomfort or indigestion in the upper abdomen often associated with heartburn, nausea, regurgitation and flatulence.

Two main causes are
1. Diseases of the upper digestive system:
a.esophagus-esophagitis, GERD (gastroesophageal reflux disease), hiatus hernia
b.stomach -gastritis, peptic ulcer, stomach cancer
c.duodenum -duodenal ulcer

2.Diseases of the gallbladder, biliary and pancreatic system
a.gallbladder -cholecystitis, gallstone
b.biliary system - obstrion in the bile duct
c.pancreas -pancreatitis, cancer of pancreas

Other causes:
3.Mechanical factors such as overeating, rapid eating,faulty chewing of food

4.Excessive irriation of gastic mucosa such as
a.food - caffiene, alcohol, poorly digested spices, nuts
b.food that relax lower esophageal sphincter such as chocolates
.
5.Psychogenic causes of excessive production of acidic gastric juice such as stress and anxiety which automatically increase the production of the acid as a result of sympatheic nervous reaction

6.Drugs: prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, steroids

7.systemic diseases, such as pernicious anemia,heart failure with ascites, uremia and diabetes

8.hereditary- some gastric patient has family history of gastric problem. Blood group O tends to have more gastitis while Blood group A has a tendency towards stomach cancer.

9.smoking has been associated with increased acid formation
and indigestion

The most common symptoms of dyspepsia are
1.upper abdominal upset or epigastric pain.

2. belching, abdominal bloating,

3.nausea, and vomiting

4.burning sensation in the upper abdomen or in the chest(heart burn).

5.regurgitation

Dyspepsia is diagnosed through one or more medical tests:
1.Upper gastrointestinal endoscopy.
The doctor eases an gastroscope, a thin tube containing a tiny camera, through your mouth  and down into your stomach to look at the stomach lining.
The doctor will check for inflammation and may remove a tiny sample of tissue for tests(biopsy). The biopsy will detect how bad is the inflammation or whether there are underlying cancer cells. In additional if any polyps (benign swelling of the lining of the stomach) are detected, they are removed at the same time and sent for biopsy.

2.X-rays of the stomach -barium meal or
gallbladder-cholecystography

3.Ultrasound scan of liver, pancreas, gallbladder

4.Blood test. The doctor may check your blood for any evidence of H.pylori infection and pancreatic enzymes to exclude pancreatic causes

Urea breath test can also determine whether you have H.pylori infection

The main Treatment of Dyspepsia is usually
1.reduce stress

2.reorganization of work in such a way as to be able to handle the pressure of work better as well as to have regular meals

3.Control of diet - avoid hard foods such as peanuts , tough meat, spicy food, cold food, black coffee, strong tea,citrus fruits and their juices,carbonated beverages, deep fried or oily food.

4. Take more frequent and smaller meals.

5. Avoid alcohol and smoking

6. Avoid drugs such as aspirin, painkillers,steroids which may irritate your stomach and cause increase in acid production

Regulate eating habits  using small meals, sitting up, walking after food

Medications:
Treatment usually involves taking drugs
1.Antacids:to reduce stomach acid and thereby help relieve symptoms and promote healing. (Stomach acid irritates the inflamed tissue in the stomach.)

2.H2 Antagonist: to reduce to production of acidic gastric juice.(cimetidine, ranididine,omeprazole, Nexium etc)

3. Antispasmodics: anticholinergic drugs like buscopan,  librax reduce the spasm in the stomach and duodenum

4.If your Dyspepsia is caused by an infection, that problem may be treated as well. For example, the doctor might prescribe antibiotics to clear up H. pylori infection. Once the underlying problem disappears, the Dyspepsia usually does too. Talk to your doctor before stopping any medicine or starting any Dyspepsia treatment on your own.

5.Surgery may be required in cancer of stomach, pancreas, gallstones

The Complications of untreated Dyspepsia are:
gastric ulcers and strictures
bleeding

Prognosis :
good to excellent except for cancer of stomach and pancreas

A Family Doctor's Tale - DYSENTERY

DOC I HAVE DYSENTERY

Dysentery is an acute invasive infection  of the lining of the intestines caused by a micro-organism such as bacteria or paraste resulting in leakage of fluid from the cell into the intestine(diarrhea) sometimes with bloody mucus, abdominal pain or vomiting.

The causes of Dysentery are:
Bacteria:
1.Shigella

2.E.Coli

Parasitic:

amebic

Transnission occurs most often by close personal contact through hands or soiled clothing or fecal-oral contamination.

Stools can contain red blood cells and white blood cells.

There may blood in the stools.

The symptoms of Dysentery are:
1. watery diarrhea with blood and mucus

2. cramping abdominal pain

3. fever

4. headache and bodyaches

5. serious fluid loss especially in children

6. loss of appetite and energy

Dysentery is transmitted through:
Dysentery can be highly contagious.

The germs are commonly transmitted by people with unwashed hands.

People can get the germs through close contact with infected individuals by sharing their food, drink, or eating utensils, or by eating food or drinking beverages that are contaminated with the germs.

The diagnosis of Dysentery is made by:
1.Doctors generally diagnose Dysentery based on the symptoms and a physical examination.

2.stool sample to test for microscopic examination and stool culture

Microscopic examination shows the presence of red blood cells and polymorphs white blood cells.

Treatment of  Dysentery is by:
1.Because of the excessive fluid loss, correction of fluid and electrolyte balance is the most important part of treatment.

Prompt treatment may be needed to prevent dehydration which is the loss of fluids from the body. Important salts or minerals, known as electrolytes, can also be lost with the fluids. Dehydration can be caused by diarrhea, excessive urination, excessive sweating, or by not drinking enough fluids because of nausea, difficulty swallowing, or loss of appetite.

The symptoms of dehydration are
excessive thirst
dry mouth
little or no urine or dark yellow urine
sunken eyes
severe weakness or lethargy
dizziness or lightheadedness

Mild dehydration can be treated by drinking liquids.

Severe dehydration may require intravenous fluids and hospitalization.

Untreated severe dehydration can be life threatening especially in babies, young children and the elderly.

2.Antibiotics is necessary,the choice of which depends on the sensitivity of bacteria to the antibiotic.

Anti parasitic drug for amebic dysentery is usually metronidazole

3.Relief of symptoms include an antispasmodic drug to stop abdominal cramps, medicine to harden the stools such as kaolin and slow down the intestinal movement (lomotil or loperamide).

The following steps may help relieve the symptoms of Dysentery.
1.Allow your gastrointestinal tract to settle by not eating for a few hours.

2.Sip small amounts of clear liquids or suck on ice chips if vomiting is still a problem.

3.Give infants and children oral rehydration solutions to replace fluids and lost electrolytes.

4.Gradually reintroduce food, starting with bland, easy-to-digest food, like porridge or soups.

5.Avoid dairy products, caffeine, and alcohol until recovery is complete.

6.Get plenty of rest.

Prognosis:
Symptoms usually improve within one to 2 days after the onset of treatment.

Outcome is usually excellent with appropriate treatment.

Prevention of dysentery is by:
1.washing of  hands thoroughly for 20 seconds after using the bathroom or changing diapers

2.washing of  hands thoroughly for 20 seconds before eating

3.disinfecting contaminated surfaces such as counter tops and baby changing stations

4.Avoid eating or drinking foods or liquids that might be contaminated

5.Avoid raw vegetables or meat

A Family Doctor's Tale -CONTACT DERMATITIS

DOC I HAVE CONTACT DERMATITIS


Contact Dermatitis is a common skin condition which presents as a erythematous or vesicular rash on face, neck, hands and other areas in contact with external environmental substances.

The cause of Contact Dermatitis is related to the exposure of the skin to the external environmental substances, chemicals or plants.

There may be a latent interval of days or years between first exposure and development of sensitization.

Virtually any substance can cause sensitivity of the epidermis of the skin.

Some possible triggers are:
1.Metals especially nickel from bracelet, pendants, neck chains, or chrome from watches, etc

2.Dyes from comestics,lipstick, clothes, hair dyes

3.Chemicals from perfumes, soaps, shaving cream, antiseptic creams

4.drugs such as penicillin, sulphonamides, tetracycline, neomycin, aspirin, NSAIDs, ointment bases,

5.Plants such as poison ivy, flowers, pollens, primrose just to name a few can cause skin allergy

6.Animals - the fur from animals can cause contact dermatitis

Contact Dermatitis affects both sexes equally.

Symptoms and signs of Contact Dermatitis are:
Typical features of Contact Dermatitis are:

1.vesicular or bubbles in areas most exposed to the external environmental substance

2.erythrematous or red rashes in areas most exposed to direct contact

3.hives or urticaria from direct contact such as pollens

4.weeping eczema in severe cases

Diagnosis:

skin patch tests

Treatment of an Contact Dermatitis treatment routine is:

1. Avoid exposure to causative substance

2.application of nonprescription corticosteroid creams and ointments to reduce inflammation
if the condition persists, worsens, or does not improve satisfactorily.

Hydrocotisone cream and ointment are preferred to prevent side effects such as skin thinning.

3.For severe flare-ups, your doctor may prescribe oral corticosteroids (this treatment is not recommended for long-term use).

4.sedative antihistamines are sometimes used to reduce the itch

Prognosis of Contact Dermatitis:

good to excellent in most cases with avoidance of contact substance

Recurrence is always possible due to recontact or new substance allergy

Prevention of Contact Dermatitis is by:
Contact Dermatitis can usually be avoided with some simple precautions.

1.Avoid contact with the causative environmental substance which has been identified

2.Avoid contact with drugs or cosmetics which can trigger off Contact dermatitis

3.Avoid contact with foods having dyes and preservatives

A Family Doctor's Tale - PHOTO DERMATITIS

DOC I HAVE PHOTO DERMATITIS

Photo Dermatitis is a common skin condition which presents as a erythematous or vesicular rash on face, neck, hands and other areas exposed to sunlight.

The cause of Photo Dermatitis is related to the exposure of the skin to the sun.
However some possible triggers are:
1.Genetic

Genes play a part in Photo Dermatitis as the condition runs in families

2.External causes

Photo sensitivity:certain exogenous sensitizers play a part in the development of Photo Dermatitis.

a.drugs such as phenothiazines, thiazides and tetracycline

b.cosmetic such as lipstick, perfumes, soaps, shaving cream, antiseptic creams, even sun screening agents (especially if they contain coal tar)

c.irritating chemicals which exaggerated the photosensitzing effect of the sun

d.sunburn reaciion which aggarvated the skin to react as rashes.

e.Photo allergic rash which persist for years

f. injury by ultraviolet light

g.feeling too hot and/or sweating will cause an outbreak.

h.Stress can also sometimes aggravate an existing flare-up.

Photo Dermatitis affects both sexes equally.

The symptoms and signs of Photo Dermatitis are:
Typical features of Photo Dermatitis are:

1.vesicular or bubbles in areas most exposed to light

2.erythrematous or red rashes in areas most exposed to light

3.some occurs following severe sunburn

4.some are seasonal with recurrance in early spring and summer

5.actinoid reticuloid skin rash affecting the face and hands are also seen in chronic photo dermatitis patients

Photo Dermatitis is  diagnosed by:
1.History and appearance of the rash

2.Photo patch testing

3.Determination of light wavelength causing photo dermatitis

Treatment of an Photo Dermatitis treatment routine is:
1. Avoid ultraviolet light especially long wave ultraviolet light

2. application of lotions or creams to protect the skin against the sun

3.chloroquine sulphate 200mg daily may be useful for some patients over short periods

4.application of nonprescription corticosteroid creams and ointments to reduce inflammation
if the condition persists, worsens, or does not improve satisfactorily.

Hydrocotisone cream and ointment are preferred to prevent side effects such as skin thinning.

5.For severe flare-ups, your doctor may prescribe oral corticosteroids (this treatment is not recommended for long-term use).

6.sedative antihistamines are sometimes used to reduce the itch

Prognosis:

1.good to excellent in most cases with phot toxic eruptions

2.good to fair with photo allergic reactions

3.Some patients reacts persistently to light without exposure to an antigen.

Prevention of  Photo Dermatitis is by:
Photo Dermatitis outbreaks can usually be avoided with some simple precautions.

The following suggestions may help to reduce the severity and frequency of flare-ups when exposed to the sun:

1.use sun screen

2.Avoid drugs or cosmetics which can trigger off photo dermatitis

3.Avoid sweating or overheating

4.Reduce stress

5.Avoid harsh soaps, detergents, and solvents

6.Avoid environmental factors that trigger allergies (e.g., pollens, molds, mites, and animal dander)

7.Be aware of any foods that may cause an outbreak and avoid those foods