Painless passage thro' the throat

By Chris Fernando

Q: My father who is 65, recently vomited blood. Our doctor suspects a stomach ulcer or some bleeding problem with the swallowing passage. My father also suffers from cirrhosis of the liver. Our doctor suggests that he undergoes a gastroscopy. I am rather worried about this. At his age, will he be able to survive such an ordeal? And is his condition life threatening?

Dr. Maiya says:

You have nothing to worry about since the "ordeal" you describe in your letter is totally pain free and the most reliable test to find out the cause of your father's problem.

The blood, which was in the vomittus, obviously came from the swallowing passage, stomach or stomach outlet, which is called the duodenum.

The best diagnostic tool in these cases is the gastroscope, which is a flexible fibreoptic tube connected to a TV screen. It is one metre long and has a diameter slightly smaller than the little finger of a full grown adult.

The procedure is without discomfort to the patient. Before performing a gastroscopy, the patient is asked to lie down on the left side and the throat is sprayed with a local anaesthetic thereby eliminating all sensations of the throat. If you put your finger into your throat, you will get the urge to vomit. However, after your throat is sprayed with local anaesthetic you can easily explore it with a finger since all sensations are then blocked off.

The patient is also given mild sedatives and the gastroscope is introduced through the mouth down the swallowing passage into the stomach and this is totally pain free.

The most common causes of bleeding can be from the ulcer of the stomach, swallowing passage or the duodenum. Patients with cirrhosis of the liver like your father can have severe bleeding from the rupture of enlarged veins in the lower end of the swallowing passage.

A normal person has tiny veins in the lower end of the oesophagus, but these are not enlarged or visible. Venous blood from the bowels, travels through the liver into the heart. However, in the case of a patient suffering from cirrhosis, the liver's architecture is completely deranged and there is tremendous resistance to the free flow of blood into the liver. Therefore, the venous blood from the bowels has to find an alternative pathway to reach the heart. These alternative pathways are in the lower end of the oesophagus, through the spleen and the rectro-peritonial spaces. These channels, under normal conditions, are closed but in cirrhosis of the liver, they dilate to carry the excess load of blood. The veins, especially in the oesophagus and swallowing passage, are not capable of handling this heavy load and they tend to distend. Once the limit of distension is reached, they rupture, producing torrential blood vomittus.

In your father's case, because of the history of cirrhosis, it is possible that he has bled from oesophagial varices. This condition can be detected through the gastroscope which, in addition to being used for diagnostic purposes can also be used for therapeutic procedures.

For bleeding varices, a needle attached to a fine tube can be introduced through the gastroscope and sclerosent can be injected into and around the veins to stop the bleeding. Under similar conditions of bleeding veins of the oesophagus, a rubber band applicator can be attached to the end of the endoscope and the bleeding veins can be strangulated arresting the bleeding immediately. This is known as rubber band ligation of oesophagial varices and is a superior method to injections. Several sessions of injections and rubber band ligations or a combination of both are necessary to completely ablate the varices and put a stop to the recurrent episodes of bleeding, which are frequently encountered in patients with cirrhosis.

A bleeding ulcer may also cause catastrophic blood vomitting and bleeding can be arrested even temporarily to buy time for the patient till a definite procedure is planned by injecting materials, which constrict the blood vessels temporarily, through similar needles around the bleeding ulcer.

It is also worth mentioning here that the gastroscope can be used for other procedures such as dilating or widening a narrow area, which is called a stricture in the swallowing passage. This is done by passing a small narrow inflatable tube, which goes through one of the channels in the gastroscope and is passed beyond the stricture and the balloon being inflated to widen the opening.

Similarly, in patients with inoperable cancer of the swallowing passage with extreme narrowing of the swallowing passage which prevents the patients from taking liquids or solids the passage can be widened and permanent metallic expansile stents put across the narrowing to keep them wide open, with the aid of a gastrocope. All these procedures that are mentioned above are done under sedation with dramatic relief and long or short term benefit to the patient. So as you can see now, the gastroscope is a very useful instrument for diagnostic and many therapeutic procedures are done under sedation with no undue discomfort to the patient who is out of the hospital within hours of the test.

To answer your second question, the bleeding varices can be ablated as I have mentioned with endoscopic bonding or sclerotherapy.

However, it must be stressed on this occasion that the insult the liver has suffered will continue and ultimately, it is the destructive process of the liver that will decide the life span of the patient.

Up goes that sugar

What is diabetes? Diabetes is a disease in which your body is unable to properly use and store glucose (a form of sugar). Glucose backs up in the bloodstream — causing the blood glucose or "sugar" to rise too high.

There are two major types of diabetes. In Type 1 (also called juvenile-onset or insulin-dependent) diabetes, the body completely stops producing any insulin, a hormone that enables it to use glucose found in foods for energy. People with Type 1 diabetes must take daily insulin injections to survive. This form of diabetes usually develops in children or young adults, but can occur at any age. In Type 2 (also called adult-onset or non insulin-dependent) diabetes, the body produces insulin, but not enough to properly convert food into energy. This form of diabetes usually occurs in people who are over 40, overweight, and have a family history of diabetes.

How do people know if they have diabetes? People with diabetes frequently experience certain symptoms. These include being very thirsty, having to urinate frequently, weight loss, increased hunger, blurry vision, skin infections, wounds that don't heal and extreme unexplained fatigue.

In some cases, there are no symptoms — this happens at times with type 2 diabetes. In this case, people can live for months, even years without knowing they have the disease. This form of diabetes comes on so gradually that symptoms may not even be recognized. In either case, a simple blood sugar test- or several of them- will confirm the diagnosis.

Who gets diabetes? Diabetes can occur in anyone. However, people who have close relatives with the disease are somewhat more likely to develop it. The risk of developing diabetes also increases as people grow older. People who are over 40 and overweight are more likely to develop diabetes.

How is diabetes treated? There are certain measures that everyone who has diabetes, whether type 1 or type 2, needs to take to be healthy. The diet needs to be planned and the amount of exercise undertaken by the patient needs to be planned too.

Everyone with type 1 diabetes, and some people with type 2 diabetes, also needs to take insulin injections. Some people with type 2 diabetes take pills called "oral agents" which help their bodies produce more insulin and/or use the insulin it is producing better. Some people with type 2 diabetes can manage their disease with weight loss, diet and exercise alone and don't need any medication.

Also, people with diabetes need to learn how to monitor their blood sugars day-to-day at home using home blood sugar monitoring.

When a stroke strikes

A stroke occurs when the blood supply to a part of the brain is suddenly interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding the brain cells.

The symptoms of stroke are easy to spot: sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking; dizziness; or loss of balance or coordination.

Brain cells die when they no longer receive oxygen and nutrients from the blood or when they are damaged by sudden bleeding into or around the brain. These damaged cells can linger in a compromised state for several hours. With timely treatment, these cells can be saved. Stroke is diagnosed through several techniques: a short neurological examination, blood tests, CT scans, MRI scans, Doppler ultrasound, and arteriography.

Strokes seem to run in some families.Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. The most important risk factors for stroke are hypertension, heart disease, diabetes, and cigarette smoking.

Other risks include heavy alcohol consumption, high blood cholesterol levels, illicit drug use, and genetic or congenital conditions. Some risk factors for stroke apply only to women. Primary among these are pregnancy, childbirth, and menopause. Generally, there are three treatment stages for stroke: prevention, therapy immediately after stroke, and post-stroke rehabilitation.

Therapies to prevent stroke are based on treating an individual's underlying risk factors. Acute stroke treatment tries to stop a stroke while it is happening. Post-stroke rehabilitation is to overcome disabilities that result from stroke damage.

Although stroke is a disease of the brain, it can affect the entire body. Some of the disabilities that can result from stroke include paralysis, speech problems, emotional difficulties, daily living problems, and pain.

Defuse those triggers in time

Stress' is now a fashionable word and some thing that even doctors frequently cite as a cause of various illnesses. It means that you are under constant pressure-or you believe you are- to meet commitments either to your job, family or socially, and find these demands increasingly difficult to cope with. What is this 'stress', how do you handle it and what can you do to reduce it?

To cope with stress the body produces adrenaline, known as the 'fight or flight hormone', which prepares the body for action. However, when this normal reaction is not allowed to take place damaging stress is often the result.

As stress increases, a recognised behaviour pattern emerges.

Constant fatigue, irregular sleep patterns, poor concentration, short-term memory, self-doubt accompanied by neglect of the family, personal appearance and other responsibilities leading to increased irritability are some of them.

It is helpful to recognise the stress triggers and defuse them in time. Remember that some can be avoided whilst others cannot- for example, moving house or a death in the family. But more commonly, stress triggers could be anything from a late train to traffic jams or long queues at the bank leading to a delay in keeping an appointment.

Exercise is an excellent way to relieve frustration and stress, as are relaxation techniques such as yoga. Alcohol and smoking will at best only provide short-term relief from stress and are not solutions to it. Also, don't rush your food - it is important to relax over meals. But perhaps the best solution to stress is a good night's sleep.

And if this is not forthcoming, some strategies may help: A glass of warm milk, reading a familiar book in bed, adopting a routine pattern leading up to bedtime, a hot bath and yes, settling all arguments and anxieties before bedtime.

If all this does not work and distress is still being experienced, perhaps then it is time to see a doctor who may even suggest medication as a means of help.

Hard facts on kidney stones

Kidney stones, one of the most painful of the urinary disorders, are not a product of modern life. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy.

Nevertheless, the ailment has persisted and is even today a common surgical condition. A kidney stone is a hard mass developed from crystals that separate from the urine and build up on the inner surfaces of the kidney.

Normally, urine contains chemicals that prevent the crystals from forming. These inhibitors do not seem to work for everyone, however, so some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without being noticed.

Kidney stones may contain various combinations of chemicals. The most common type of stone contains calcium in combination with either oxalate or phosphate. These chemicals are part of a person's normal diet and make up important parts of the body, such as bones and muscles. A less common type of stone is caused by infection in the urinary tract. A person with a family history of kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney diseases, and metabolic disorders such as hyperparathyroidism are also linked to stone formation.

Usually, the first symptom of a kidney stone is extreme pain. The pain often begins suddenly when a stone moves in the urinary tract, causing irritation or blockage.

Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin.

If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. As a stone grows or moves, blood may appear in the urine. As the stone moves down the ureter closer to the bladder, you may feel the need to urinate more often or feel a burning sensation during urination. If fever and chills accompany any of these symptoms, an infection may be present. In this case, you should contact a doctor immediately.

Sometimes "silent" stones—those that do not cause symptoms—are found on x-rays taken during a routine examination. These stones would likely pass unnoticed. More often, kidney stones are found on an x-ray or scan on someone who complains of blood in the urine or sudden pain.

These diagnostic images give the doctor valuable information about the stone's size and location.

Blood and urine tests help detect any abnormal substance that might promote stone formation.

The doctor may decide to scan the urinary system using a special x-ray test called an IVP (intravenous pyelogram). The results of all these tests help determine the proper treatment.

Fortunately, surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water (2 to 3 quarts a day) to help move the stone along.

Surgery should be reserved as an option for cases where other approaches have failed or shouldn't be tried. Surgery may be needed to remove a kidney stone if it:

-Does not pass after a reasonable period of time and causes constant pain.

-Is too large to pass on its own or is caught in a difficult place

-Blocks the flow of urine.

-Causes ongoing urinary tract infection.

-Damages kidney tissue or causes constant bleeding.

-Has grown larger (as seen on follow-up x-ray studies).

Until recently, surgery to remove a stone was painful and required a lengthy recovery time (4 to 6 weeks). Today, surgical treatment for these stones is greatly improved, and a new technique called 'lithotripsy' greatly reduces hospitalization and recovery time.

If you've had more than one kidney stone, you are likely to form another; so prevention is very important.

A simple and most important lifestyle change to prevent stones is to drink more liquids—water is best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two quarts of urine in every 24-hour period.

You may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base. If you have very acidic urine, you may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine.

These decisions are however best left to your doctor. The key fact to keep in mind is that if symptoms like those mentioned above suggesting kidney stones are experienced, medical advice should be sought without delay.

From night service to round-the-clock help

What do you do if your child develops high fever in the middle of the night? Or if your elderly father complains of a sudden pain in the chest?

For many living in Colombo and the suburbs, the answer would be to summon Medi-Calls, the emergency medical service that provides an effective help-line to those in need of treatment or even medical advice. Launched in 1983 by Dr. K. Rajendra, initially as a night service, Medi-Calls now has 21 doctors on its staff working on a roster, supported by paramedics and trained nurses, responding to calls throughout the day and night.

"I realised the need for a service of this kind when patients who came to my clinic kept asking me whether they could call me in the night if there was an emergency.

"I assured them that I would always come, but the frequency of the queries told me that getting medical assistance in an emergency was indeed a problem for lots of people," Dr. Rajendra said.

Medi-Calls now has some 8,000 householders registered. And on average, they receive around 20 calls a day, most in the case of accidents at home, ailing elders, children with sudden high fever and adults with chest pains. Any member of the household registered can call on the Medi-Calls hotlines, and once the name and registration number are given, and the nature of the emergency described, Medi-Calls despatches a doctor and, if necessary an ambulance to the home.

If the patient requires admission, Medi-Calls personnel handle the formalities at the hospital of the patient's choice or find a hospital, even providing the overnight financial guarantee, if the need arises.

Realising that not all patients are in need of hospitalisation, and what may perhaps be needed is some sound medical advice, they now have a free help-line where anxious patients can check their doubts or obtain advice from a doctor, round the clock.

"I tell my doctors to remember that they were human beings before they became doctors," says Dr. Rajendra.

Apart from the Colombo city limits, the Medi-Calls service has been extended to Dehiwela, Mount Lavinia, Ratmalana, Moratuwa, Maharagama, Nugegoda, Nawala, Battaramulla, Sri Jayewardenepura, Kotte, Wellampitiya, Kelaniya and Wattala.

The service has now been extended to companies to provide cover for staff members and their households.

Regular medical check-ups, well-woman clinics and vaccination programmes have also been lined up as part of their emphasis on preventive medicine.