Year: 2002

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Irritable Bowel Syndrome

Are your guts driving you nuts?

Then the problem may be in your head. Not in your guts.

What’s your head got to do with your guts?

Well, we are talking about stress. Stress can play havoc with your body. Stomach and intestine are very sensitive to stress. And the result is – irritable bowel syndrome (IBS).

IBS is not like other conditions. There are no definite abnormalities to find in a patient with IBS and there are no tests to confirm the diagnoses.

How do we know a person has irritable bowel syndrome?

Mainly by symptoms of abdominal pain, bloating and irregular bowel movements. And by ruling out other conditions of the gastrointestinal tract.

IBS is a complex condition that affects a person’s psychology (emotional and behavioural characteristics). A physician treating this condition must have a good understanding of the problem. He should be able to dedicate time and energy to help his IBS patients.

IBS is considered to be a functional disorder of the gastrointestinal tract. But there is high incidence of psychiatric disorders in patients with IBS – panic disorder, major depressive disorders, and phobias.

Patients have to realise that they may need psychological treatment for a physical condition. And having irritable bowel does not mean a person is mentally ill. Antidepressants and medications that inhibit anxiety have been shown to be effective in IBS. But these drugs have to be used with care.

Stress-induced anxiety can make symptoms of IBS worse. The source of stress can be internal (from within your own body) or external (from your environment). IBS patients experience higher levels of anxiety and fatigue than do healthy people.

In more severe, treatment-resistant IBS, psychotherapy has been proven to be useful. But there is no evidence to suggest that psychotherapy is beneficial in patients with mild IBS. Before psychotherapy is instituted, a physician should rule out some of the common conditions of the gastrointestinal tract – ulcers, inflammation (inflammatory bowel disease), and cancer.

Management of IBS poses a big challenge to a physician. Many drugs are available in the market for use in IBS. But none of them have proven benefits. Some of them may act as placebo. Smooth muscle relaxants tend to help relieve abdominal pain with or without relief of other symptoms of IBS. Loperamide (Imodium) is beneficial in patients who have diarrhoea as a predominant symptom.

Current treatment of IBS includes advice on high fibre low fat diet, smooth muscle relaxant, agents to stop diarrhoea or bloating and psychotherapy or psychoactive drugs to take care of depression or anxiety.

If your mind is playing games with your guts then stop and ask, “Who is playing games with my mind?” If it is your own thought process then take control of it – try exercise, laughter and meditation. If it is your environment, then get out of that environment. Create your own environment of happiness and relaxation. It can be done, if you have the desire and willingness to accept change.

Remember, if you take care of ELMOS (exercise, laughter, meditation, organic healthy food, stress management) then ELMOS will take care of you and your IBS!

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Skiing and Stress Relief

Let’s talk about skiing and stress relief.

In last Friday’s Talk of the Town column, Angus Henderson wrote about Hidden Valley Ski Resort. I am glad he did that. I am very fond of that place.

I like to commend Kevin Fischer and his staff. They do a wonderful job of running the place. Kevin is a very approachable fellow. Always has a smile on his face. His staff is always very cheerful, friendly and helpful.

Kevin’s presence is always visible and his hands-on leadership is very evident.

My family and I love Hidden Valley. I started taking ski lessons eight years ago when my son joined the Nancy Green program. He has been a fast learner. He now snowboards.

My daughter also likes to ski but my wife felt that she would be a good family cheerleader than a skier! And supply us with hot chocolate, lunch and snack during breaks! Not a bad deal!

For me the progress has been slow. I have fear of heights and speed. And as a surgeon, I did not want to break my wrist and be out of commission for several months. But I was determined to learn and be with my family.

I was born and brought up in Tanzania. I had never seen snow in Africa except in pictures. Mount Kilimanjaro in Tanzania is famous for snow-capped peak. But I never got a chance to get there. In any case, there is no skiing on Mount Kilimanjaro.

Over the last eight years, I have made slow but sure progress. Many young instructors and friends at Hidden Valley, Sunshine and Canada Olympic Park helped me get through my fears. Now I can ski all the hills at Hidden Valley except Suicide and Showoff. This year my target was to be comfortable on the Hidden Valley run. I successfully did it several times. Next year, the plan is to get over the fear of Suicide run! Showoff, probably never!

Each year, by October, I am looking forward to winter, snow and skiing. I find skiing very relaxing and good for stress relief. A good example is what happened last week. It was a busy week and in some respects a very traumatic week at work. It culminated in a very exhausting and draining Friday meetings.

I am glad I had a weekend off to recover. For two days, my son and I went skiing at Hidden Valley. The weather was great. Snow was excellent. The weekend of skiing completely refreshed me.

At Hidden Valley, you are amongst happy people. Unlike golfers, skiers are always smiling and are ecstatic when they come flying down the hills. Skiers don’t shout “fore” and you don’t hear anybody swear!

Skiers are not rushing or pushing you to keep moving. They don’t phone the clubhouse because of “slow play”. There is no marshal in a red power cart chasing you around the ski hills. Instead, you see helpful ski patrols and instructors.

At Hidden Valley, beginners and experienced skiers have fun together. Good skiers don’t look down on beginners or show any signs of arrogance. In fact, they are willing to share their experience. It’s like a big happy family.

Do you know what happens to a golfer after he dies? Saint Peter sends him straight to heaven because he has suffered enough on the golf course!

For skiers, heaven is at Hidden Valley and other ski resorts. Skiers don’t have to worry about life after death. It is heavenly all the way!

Now, am I putting my golf club membership in jeopardy? Glen Carr, don’t worry. I will be there when the golf course opens. In summer, golf course cannot be worse than health care politics!

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Patients Who Smoke

Dr. Frederick Ross of Winnipeg must have become a household name. He has been extensively interviewed and quoted in the media. And his recent actions have rekindled the debate about individual’s responsibility to his own health and physician’s responsibility to educate his patients on preventive medicine.

What did Dr. Ross do?

Three months ago, he informed all his patients that he would not treat smokers who are unwilling to give up the deadly habit. They were given 90 days to quit. The deadline was last week. That’s when Dr. Ross hit the headlines. Some people complained that Dr. Ross’s action was unethical. Manitoba’s licensing body for Physicians thinks otherwise.

As we know, tobacco use is the leading preventable cause of death in Canada. It is responsible for one in five deaths. Half of regular smokers die prematurely of tobacco-related disease. Many patients continue to smoke although they have known or experienced ill health due to smoking.

What are the obstacles to quitting?

The main obstacle to quitting is the addictive nature of nicotine, says an article in the New England Journal of Medicine (NEJM).

Nicotine causes tolerance and physical dependence. If you quit smoking then expect withdrawal symptoms like irritability, anger, impatience, restlessness, difficulty concentrating, insomnia, increased appetite, anxiety, and depressed mood. These symptoms may vary widely in intensity and duration.

The withdrawal symptoms begin a few hours after the last cigarette, peak two to three days later, and wane over a period of several weeks or months.

The second obstacle to quitting is the psychological factor – tobacco use is a learned behaviour, cigarettes become part of a person’s daily routine, says the NEJM article.

It is associated with events, such as finishing a meal; handling stress and negative emotions such as anger or anxiety. To stop smoking, a smoker must learn new coping skills and break old patterns.

Smokers who have good intention to quit have two problems: staying free of cigarettes for a long period of time and putting on weight.

What is effective in encouraging smokers to quit?

A physician can do what Dr. Ross did. But scientifically, two approaches have been found to be effective: counselling and nicotine replacement therapy. Each is effective by itself, but the two in combination achieve the highest rates of smoking cessation, says the NEJM article.

Studies have shown that a physician’s advice to stop smoking increases the rates of smoking cessation among patients by approximately 30 percent.

One report in the Medical Post says that half the specialists surveyed never counselled patients on smoking cessation. That burden seemed to fall on the family physicians, who were eight times more likely to ask patients about a quit date than other physicians.

Nicotine replacement therapy comes in different forms: gum, skin patch, a nasal spray, and a vapour inhaler. Combination of counselling and drug therapy achieves typical rate of cessation at 40 to 60 percent at the end of drug treatment and 25 to 30 percent at one year.

Changing public behaviours is difficult. “The first reform is to stay healthy,” says Mazankowski report. We know that relatively small changes in our lifestyle can markedly reduce several major diseases. But are we ready to do that?

Through these columns and through CHAT TV’s “Medical Moments” we have tried to send the same message of self-help and improvement in once life-style. The slogans we have used are: help your doctor to keep you healthy and if you take care of ELMOSS then ELMOSS will take care of you!

So, what did you do today to keep yourself healthy?

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Vitamin B12

Dear Dr. B: Thank you for your columns on Vitamin C and other vitamins. What about vitamin B12? Many people are on B12 injections on regular basis. Why is B12 important? Yours, Ms. B12.

Dear Ms. B12: Vitamin B12 deficiency is a common problem that affects the general population and the elderly in particular. Persons with the deficiency may have no symptoms or may have symptoms related to blood disorder or disorders of the nervous system including psychiatric problems.

Vitamin B12, also known as cobalamin, was first isolated in 1948 and was immediately shown to be effective in the treatment of pernicious anaemia. Recently, interest in the vitamin has been renewed because of the recognition that B12 deficiency occurs in 3% to 40% of the general population.

Vitamin B12 is essential for good health. It is obtained primarily from animal proteins (i.e., red meat, poultry, fish, eggs, and dairy). But the vegetarians can get enough of it from legumes. The cause of B12 deficiency is not usually poor diet but problems with absorption in the gastro-intestinal tract.

Absorption of vitamin B12 from foods is complex; a defect in any step can lead to deficiency. In the stomach, gastric acid and pepsin is required for digestion of B12. In the upper small intestine, pancreatic enzymes and an alkaline pH is necessary. B12 is absorbed from the terminal ileum (last part of the small intestine where it joins the colon).

The liver contains most of the body’s B12 (about 1.5 mg), followed by the kidneys, heart, spleen, and brain. Normal body stores of vitamin B12 range from 2 to 10 mg; daily losses are 2 to 5 micrograms. The stored B12 can last us two years in conditions where our body is deprived of B12.The latest Recommended Dietary Allowance (RDA) for vitamin B12 is 2.4 micrograms/day for persons aged 14 to 70 years; the average diet contains about 5 micrograms daily.

The diagnoses of B12 deficiency is made by checking the blood levels in patients who have symptoms or who are prone to B12 deficiency. Treatment is by B12 injections on regular basis for the rest of person’s life.

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A reader wants to know the following:

What is the difference between micrograms (ugm.), milligrams (mg.) and International Units (IU)?

1000 micrograms is 1 milligram.

International unit (IU):
Is a unit used to measure the activity (that is, the effect) of many vitamins and drugs. For each substance to which this unit applies, there is an international agreement specifying the biological effect expected with a dose of 1 IU. Other quantities of the substance are then expressed as multiples of this standard. Examples: 1 IU represents 45.5 micrograms of a standard preparation of insulin or 0.6 microgram of a standard preparation of penicillin. Consumers most often see IU’s on the labels of vitamin packages: in standard preparations the equivalent of 1 IU is 0.3 microgram (0.0003 mg) for vitamin A, 50 micrograms (0.05 mg) for vitamin C, 25 nanograms (0.000 025 mg) for vitamin D, and 2/3 milligram for vitamin E. Please note: for many substances there is no definite conversion between international units and mass units (such as milligrams). This is because preparations of those substances vary in activity, so that the effect per milligram of one preparation is different from that of another.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!