Author: noorali

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Lymph Glands

Dear Dr. B: What are the lymph glands? Why do I have lymph glands in the neck? Do I have cancer?

Answer: The lymph glands are also known as lymph nodes. A lymph node acts as a filter and is part of the lymphatic system. Tissues in the body release fluid called lymph. Lymph is transported through the lymphatic system, is filtered through the lymph nodes and the filtered fluid is then transported to the blood to maintain fluid balance.

Lymph nodes contain lymphocytes which destroy bacteria and viruses. When the body is fighting infection the lymph nodes produce more lymphocytes. The activity in the lymph node is increased and the node gets enlarged.

Our body has approximately 500-600 lymph nodes. They are found in the underarms, groin, neck, chest, and abdomen. They vary in size from few millimeters to couple of centimeters. Normally, they are not palpable on physical examination unless they enlarge due to infection or tumour.

Enlarged lymph nodes due to viral infection are “reactive” in nature and are usually small, firm and non-tender and they may not go away for weeks to months. Enlarged nodes due to bacterial infection are usually tender and more than a centimeter large. The most common site is the neck. These nodes get enlarged due to infection in the mouth, throat or the scalp. This may be associated with fever.

There are many other causes of lymph node enlargement such as: eczema, mono, tuberculosis, cat scratch disease, cancer (Hodgkin’s disease, non-Hodgkin’s disease, leukemia or metastatic cancer from other site).

A good history and physical examination is important in a patient presenting with persistent enlarged lymph node. This may give us a clue regarding the origin of the problem. Clinically, we may find that there is more than one area of enlarged nodes. The liver and spleen may be enlarged as well as they are part of the lymphatic system.

Patient is initially treated with 10 days of antibiotics. If the node does not respond to antibiotics then further investigations should be done to check for other causes of enlargement.

Blood tests, ultrasound and chest x-ray may give us more information. Finally, CAT scan, fine needle aspiration biopsy or open biopsy will be required to get to the bottom of the problem.

Whether you have cancer or not depends on how far the investigations have been done to answer this question. Clinical diagnosis of cancer is not always possible. Needle biopsy or open biopsy is usually necessary.

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Did you know that 25,000 Canadians die prematurely each year because of diet-related diseases? (CMAJ February 28, 2006).

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Gallstone Surgery

Dear Dr. B: Who needs treatment for gallstones?

Answer: Sooner or later all patients with gallstones need treatment. The treatment is surgery. The question is: should it be sooner or later?

Once upon a time, the surgical procedure of choice was open cholecystectomy. In fact, Langenbuch carried out the first cholecystectomy in 1882. Patients who undergo open cholecystectomy have a long surgical incision in the abdominal wall, have to stay in the hospital three to five days, consume fair amount of pain killers for post-operative pain and the recovery time at home is three to six weeks.

Things have changed in the last 15 to 20 years. Now most patients undergo laparoscopic cholecystectomy when there is an indication for surgical removal of the gallbladder. Laparoscopic cholecystectomy was first performed in France in 1987. In this procedure, there are four tiny incisions in the abdominal wall, the hospital stay is usually overnight, the amount of pain killers required after surgery is minimal and the recovery time at home is usually less than one week.

Prophylactic cholecystectomy is done only in few exceptional cases. Otherwise, gallstone surgery is required only if you have symptoms. The most common symptom is recurrent attacks of biliary colic. The colicky pain is in the upper abdomen usually on the right side. Sometimes the biliary colic can present as chest pain and some people think they are having a heart attack.

The timing of surgery depends on how often you get the attacks of pain. If you are getting recurrent attacks then the surgery is planned to be done within a few days. If you settle down after one or two attacks then the surgery can be done within a few weeks.

Second most common indication for surgery is complications of the disease such as acute cholecystitis and obstructive jaundice. In acute cholecystitis, the gall bladder is acutely inflamed and the patient undergoes urgent surgery, usually within 24 to 48 hours of hospitalization. If the gallbladder is very inflamed and the patient is very sick then the surgeon may elect to drain the gallbladder and plan further surgery to remove the gallbladder after three to six weeks.

In obstructive jaundice the gallstone is usually lodged in the common bile duct which effectively blocks the drainage of bile from the liver and the gallbladder to the small intestine. Patients with obstructive jaundice are not acutely sick but the blockage should be taken care of before patient undergoes surgery for the gallbladder.

Patients who have vague abdominal symptoms and are found to have gallstones (gallstone dyspepsia) need careful assessment to establish gallstones are indeed the cause of the symptoms. In some of these patients, the symptoms may be due to other causes such as irritable bowel syndrome or gastro-oesophageal reflux disease. Removing the gallbladder in these instances will not help.

In gallstone pancreatitis, a stone from the gallbladder passes through a common channel formed by the common bile duct and the pancreatic duct. In the majority of patients this results in a mild attack of pancreatitis and recovery is uneventful. The majority of stones that cause pancreatitis pass spontaneously. These patients should have laparoscopic cholecystectomy done during the same hospital stay.

Early surgery in these patients does not increase post-operative complications or mortality. Early surgery also eliminates the risk of recurrent attacks of pancreatitis while the patient is waiting for elective surgery. Patients with worsening pancreatitis require further investigations as the stone may be jammed in the common and pancreatic duct.

Cholecystectomy is a very common operation and appropriate timing of the surgery is very important for patient care and safety.

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Genital Warts

Dear Dr. B: Can you please write a column on genital warts?

Answer: Sure, why not? This is the most common sexually transmitted disease. So let’s talk about it.

Genital warts are also called condylomata acuminate or venereal warts. It is estimated that one per cent of adults who are sexually active have warts in the genital or anal area. The warts are benign and are caused by human papillomavirus (HPV). There are at least 60 types of HPV. Genotypes six and 11 are found in over 90 per cent of cases of genital warts and genotypes 16 and 18 cause cervical cancer.

The virus is transferred from person to person or from contact with something someone has touched. In women, genital warts can grow on the outside or inside of the vagina, on the cervix, in the urethra or around the anus. In men, warts can grow on the tip or shaft of the penis, on the scrotum, in the urethra or around the anus.

How do I get genital warts?

Most, but not all, genital warts are sexually transmitted. Generally speaking warts are more common amongst people whose immune system is poor. But most people who get warts are healthy and well. We are all exposed to wart virus but nobody knows why certain part of our body accepts wart virus at a certain time. Therefore, prevention becomes difficult except in cases of genital warts where safe sex practice helps.

How do I know I have genital warts?

Most people with genital warts have no symptoms. By the time a person is infected and by the time the warts appear may be many months or years. The good news is most of those who get infected never develop warts.

The warts are soft fleshy lumps on or near sex organs or anus. Some people have itching or burning. Warts may be hidden in the vagina or anus.

What are the implications of the disease for patients?

The lesions are benign but they do cause psychosocial distress and may affect relationships as the warts are disfiguring and can be transmitted sexually. Practicing safe sex is important. It is advisable to use barrier protection with new sexual partners. Condoms can reduce the risk of getting genital warts but warts can spread from areas not covered by a condom. Patients who are in stable relationship may not need barrier protection because the partner is already exposed to infection by the time patient sees a doctor.

How do we manage warts?

Management of warts can be quite frustrating for patients and doctors. No specific treatment is appropriate for all patients and a person will need more than one treatment to clear the warts.

Most treatment plans will achieve clearance of virus within one to six months. In 20-30 per cent of patients new warts will occur over months or even years. Patients can treat themselves with podophyllotoxin (0.5 per cent solution or 0.15 per cent cream) and imiquimod (5 per cent cream). Imiquimod is expensive and podophyllotoxin takes longer to cure the condition.

Physicians can treat warts in the office by using trichloroacetic acid or by physical removal using cryosurgery (liquid nitrogen), electrosurgery and excision or laser treatment. In my surgical practice I use electrosurgery and/or excision.

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Pancreatitis

Dear Dr. B: When you have pancreatitis does it show up in a urine test? My son was having urine problems. He could not control it. He was seen at walk-in clinics and by his doctor and the urine test did not show anything. Then he turned yellow and he was seen by a doctor in emergency department. My son was diagnosed to have pancreatitis. It took a month for the doctors to make a diagnosis. My son survived but I am disappointed that it took so long to find out what was wrong with him.

Answer: The best way to discuss this question is to talk about pancreatitis in general and then talk about diagnosis and treatment. The information provided in the question is not sufficient enough to know why it took so long to make a diagnosis. Urinary frequency is not a classical presentation of pancreatitis.

The pancreas lies in the upper abdomen behind the stomach. Its function is to produce digestive enzymes and hormones such as insulin.

Pancreatitis is a chemical inflammation of the pancreas caused by its own digestive enzymes. Pancreatitis has two forms: acute and chronic. Most common causes of pancreatitis are gallstones and alcohol abuse. Sometimes no cause can be found. That leaves the patient and the doctor frustrated.

Patients with acute pancreatitis present with abdominal pain, nausea, vomiting, fever, and a rapid pulse. The diagnosis is made by a blood test to measure blood level of enzyme lipase. All pancreatitis patients require intravenous fluids, oxygen and pain killers to stabilize their condition. If the condition is due to gallstones then the patient will need surgical removal of the gallbladder.

An abdominal ultrasound is taken to look for gallstones and a CAT (computerized axial tomography) scan to look for inflammation or destruction of the pancreas. CAT scans are also useful in detecting cyst formation in the pancreas.

In about 20 percent of cases, acute pancreatitis can be severe, with many complications. Severe cases may cause dehydration and low blood pressure and the condition may become life threatening. The vital organs such as heart, lungs, or kidneys may fail. If bleeding occurs in the pancreas, shock and sometimes even death follow.

Chronic pancreatitis can present as episodes of acute inflammation in a previously damaged pancreas. There is intermittent or persistent abdominal pain. The chronic destruction of pancreatic tissue causes malabsorption of fat and diabetes.

Chronic pancreatitis is most often caused by alcoholism and alcohol abuse. Sometimes the cause of chronic pancreatitis cannot be determined. But any condition that causes repeated episodes of acute pancreatitis may result in chronic pancreatitis.

A quote from my friend George:

“Youth is not a time of life; it is a state of mind.” Anonymous.

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