Year: 2002

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Rectal Prolapse

Dear Dr. B: Would you do a segment on prolapsed bowel in your “What’s Up Doc” column? The cause, the treatment, and how bad this should be before surgery should be done.

Yes, here is some information about prolapsed bowel – in other words rectal prolapse. If only the lining of the rectum prolapses then it is called incomplete or mucosal prolapse. If the entire wall of the rectum is protruding then it is a complete prolapse or procidentia.

Who gets it?

In children, it occurs most frequently in the first two years of life. Then the incidence declines. It is usually a mucosal prolapse, although occasionally a complete prolapse may be present. Boys are affected little bit more than girls.

There is developmental absence of curvature in the tail bone (sacral curve). The S-shaped rectum loses its curvatures and becomes straight. Thus it is prone to prolapse. Diarrhea, constipation and bad toilet habits can precipitate prolapse.

In adults, complete prolapse is more common than mucosal prolapse. Females are affected (in one series – 84 per cent) more often than males. It most commonly occurs in women 50 years-of-age and over. Quite often these women are in their 80s and 90s.

In a small percentage of women, prolapse of uterus and rectum can occur at the same time.

In younger adults, the prolapse may occur after some sort of rectal surgery. In older adults, the prolapse may occur due to weakness of anal sphincter and tone of muscles in the pelvis supporting the rectum. It is not related to pregnancy and delivery and the number of children a woman delivers. Quite often, prolapse develops in childless women.

Prolapse is like a hernia. The rectum slides in and out of the anal sphincter. Sometimes, it may fail to reduce and gangrene may set in. Urgent hospitalization is required if the prolapse fails to reduce.

How can we treat prolapse of the rectum?

In children, it is a self-limiting condition. Institution of proper bowel habit usually fixes the problem.

In adults, several surgical and non-surgical methods have been described. That means there is no single treatment (especially surgical treatment) which guarantees cure or that it is applicable to all patients.

There are different options for adults who are in good health and are a good surgical risk. Patients with multiple medical problems who are poor surgical risk have limited options.

Two commonly used surgical procedures used for patients who are good surgical risk are:

-removal of most of the rectum and redundant sigmoid colon and joining the colon to the residual small segment of the rectum near the anal sphincter or
-Fixing the rectum in the pelvis with prosthesis like a piece of mesh or sponge.

How bad this should be before surgery should be done?

This depends on how one feels about the problem. And whether the person is a good surgical risk.

If you have a prolapse then you should get a surgical opinion. Like a hernia, it will not go away. It may remain the same or get bigger. And there is a risk of complications, if not treated. This should be weighed against the risk of surgical procedure. Talk to your doctor or surgeon.

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Risks of HRT

A month ago, it was announced that hormone replacement therapy (HRT) is causing more harm than good.

The Canadian Medical Association Journal (CMAJ) reports that the Women’s Health Initiative trial involving 16,608 women aged 50 to 79, was stopped because preliminary results showed statistically significant increases in coronary artery disease, invasive breast cancer, stroke and pulmonary embolism (clot in the lungs) in women treated with estrogen plus progestin (Prempro).

According to a report in the NEWSWEEK, last year U.S. pharmacists filled some 45 million prescriptions for Premarin and an additional 22 million for Prempro. There are more than 13 million American women on HRT.

Menopause is a natural event. But the event is very troublesome to the woman who is going through the menopause and also to the husband who has to show understanding and patience to help his wife get through these difficult years.

About 60 years ago, researchers discovered that a substance from pigs’ ovaries can put off old age and relieve menopausal symptoms.

In 1940s, pharmaceutical companies started producing estrogen from pregnant mare’s urine called Premarin. Twenty years later, the drug was being recommended for women who showed evidence of estrogen lack. Practically, all women over the age of 50.

HRT has several benefits. It was prescribed to menopausal women to relieve hot flashes, prevent heart disease and osteoporosis. There were other reasons such as improvement in quality of life.

But the risks and benefits of long-term postmenopausal HRT with estrogen alone or combined with progestin have long been a source of controversy.

This has now changed. The evidence is clear that women taking combination of estrogen and progestin have increased risk of breast cancer, heart disease, stroke and blood clots in the lungs. Potentially life threatening.

There were some benefits like reduction of hip fractures, decrease in the rates of osteoporosis and colon and rectal cancers. It also alleviates hot flashes after menopause.

What happens now?

HRT should not be used for preventative measures in healthy postmenopausal women without severe symptoms. It causes more harm than good. Other methods of prevention should be undertaken to prevent chronic illnesses.

Preventive measures for heart disease are: quit smoking, exercise, control blood pressure, control high cholesterol level, and eat a healthy diet (remember ELMOSS?).

Osteoporosis can be prevented by: exercise (starting early in life), calcium and vitamin D and in high risk women use bisphophonates.

Finally, this brief article does not cover all aspects of HRT. If you are on HRT and haven’t spoken with your family physician or gynecologist in the last one month then you better find out whether you should still be on HRT. A visit to your doctor may save your life.

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Physician Stress


Every now and then go away,
Have a little relaxation,
For when you come back to your work
Your judgement will be surer;
Since to remain constantly at work
Will cause you to lose power of judgement;
Go some distance away
Because the work appears smaller
And more of it can be taken in at a glance,
And lack of harmony or proportion
Is more readily seen.

This is what Leonardo de Vinci said about 500 years ago. This is one of my favourite quotes. I have used it before in my columns.

I hope you had a good summer and were able to get away for a while – to relax, to look back, and plan for the future.

I had a good summer. Recently, I made some work related sacrifices to have more time off for myself and for my family. Then I took three weeks off and took my family to Europe.

My wife Sabiya, and our travel agent, Jackie Kirk prepared a wonderful itinerary. And with the help of friends and family, we were able to book some nice hotels and see some nice places. We went to London, Oxford, Paris, Geneva, Venice, Florence, Pisa, Rome and Vatican City.

We travelled by Eurostar from London to Paris, and then by Rail Europe. It was a fascinating experience. Our children loved it and we all had a good time. If you want to take your time and see Europe then I recommend you do it by train. The weather was good and everything went according to plan. And the trains were always on time!

If making a living is hard work then trying to find time to look after oneself requires sacrifices and fair amount of effort. Nothing in life comes easy. There is a price to pay – depending on one’s priority.

A recent poll shows that 25 percent of Canadians work more than 40 hours a week. Most physicians are known to put in long hours. For physicians, there are many sources of stress. Physicians are supposed to be independent practitioners, but they are paid by the government and their practice is, in many ways, controlled by the government.

When patients are not happy then physicians are not happy. Physicians’ capacity to deliver good health care depends entirely on the government’s capacity to provide manpower, funding, equipment, infrastructure etc.

A recent survey shows that physicians are concerned about access and funding and are feeling stressed, says the Medical Post. A survey taken in Northern Lights health region shows that 57 percent of the doctors are dissatisfied, mostly due to stress.

The major sources of stress for physicians are:

-Insufficient medical facilities for patients
-Office details and paper work
-Administrative and committee work
-Problems with other physicians
-Therapy and patient related problems
-Personal finances

Stressed out physicians cannot provide their best to their patients. And physicians face the same sort of lifestyle and health problems as their patients. There are programs organized by Alberta Medical Association to help physicians combat stress. Some physicians do take advantage of this help.

Stress in life is not going to go away. Neither for physicians nor for the general public. But we have to learn to combat stress. Each day, I try to learn something about staying healthy to help myself, my family and my patients. Changing life long unhealthy habits requires time to think, plan and take action!

We can all do it, if we try!

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The World in Turmoil

A recent opinion poll says that Canadians are worried about their future. They do not feel as secure as they did one year ago.

Life is getting very depressing for many Canadians. How do you feel?

Summer is supposed to be one of the best times of the year. But this year, things don’t seem to be the same – or do I have a short memory? You know what I am talking about. We complained about the late snow and rain. Now we have the heat wave. Then there are mosquitoes. Their bites are itchy – they burn for days! That can be depressing.

But compared to the rest of the world, we are in heaven. The economy is booming. Crime rate is not as bad as other countries. There is no civil war – the one within the Liberal Party is not killing anyone. And most Canadians are enjoying the standard of living which some, in other parts of the world, can only dream of.

And look at the rest of the world!

The world at large continues to be in turmoil. The death and destruction in the Middle East, the Indian sub-continent and Northern Ireland continues. There are many other wars which kill thousands of people but never get reported.

AIDS is taking its toll in Africa and other places. Poverty, famine, floods, disease and deaths in thousands continue to plague the vast majority of the world.

Women and children continue to be kidnapped and murdered. Sex, violence and profanity continue to be glorified in music, movies and TV. The war against drugs and alcohol continues without any sign of success.

The big corporations continue to swindle the poor stock holders who trust their life’s savings on the basis of glorified but sometimes false reports of success. The same corporations dish out large sums of money to our politicians and the political parties. They keep the democracy alive! It’s all in the family! What can we teach our children about business and about their future careers?

Did I leave anything out? We do face some of these problems here as well. But everything is relative.

What about the millions of unspoken heroes who continue to battle unfairness in everyday life? What about their contribution to make this world a better place to live? Without them there would be no hope. One would feel less depressed if one would think about and follow the examples of these unsung heroes.

So there is hope. Every season comes to an end. Daylight comes whether we keep a wake-up alarm or not. In life certain things are going to be out of our control. But wonderful things can happen if we take care of what we can do in a positive way.

Sometime ago, my niece, Rehana, sent me an e-mail titled, “Control your destiny”. In part it said:

“Wonderful things can happen when we decide to be responsible for:
Everything we put into our mouths,
Everything we put into our minds,
And everything we put into our hearts”.

So, don’t worry, be happy. Do your bit and have a wonderful summer – don’t forget your mosquito repellent, sunscreen and a cold drink. This column will take a break for summer as well.

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