Author: noorali

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Heart and Stroke

On Friday June 3, the Medicine Hat branch of the Heart and Stroke Foundation had their 12th annual golf classic at Medicine Hat Golf and Country Club. I was one of the 160 golfers to participate in this fundraising event.

It is a big event. After 18 holes of golf (even the rain stopped for six hours for uninterrupted golf!), sumptuous dinner and some exciting prizes, I drove home thinking about the hard work done by people behind the scenes.

Darlene Neigum, Area Manager, Heart and Stroke Foundation of Alberta, NWT & Nunavut and her band of volunteers and sponsors work tirelessly to make this event a great success. It is an event worth waiting for each year.

Heart disease and stroke are subjects close to my heart as I have a strong family history of cardiac problems. The subject is also close to the hearts of many Canadians as heart disease is the number one killer in this country and in all the Western countries.

Heart and Stroke Foundation has a very interesting website (www.heartandstroke.ca). There is a lot of information to read and digest for a healthy heart.

Heart disease is usually a progressive disease occurring over many years. It is usually a result of bad genes and/or mismanagement of risk factors.

There are certain risk factors which we can influence in a positive way and there are some which are beyond our control. The risk factors that we can influence are:
-High blood cholesterol
-High blood pressure
-Lifestyle factors (lack of exercise, being overweight, smoking, drinking too much alcohol, stress) and
-Diabetes

The risk factors that we cannot change are:

-Age and gender (55+ for women, 45+ for men)
-Ethnic descent (African, South Asian, and First Nation populations are at higher risk)
-Family medical history – heart attack or stroke before age 65, angina, tendency to develop high blood cholesterol or blood pressure

Risk factors for stroke are very similar to heart disease. The best way to prevent heart disease and stroke is to work toward pursuing a healthy lifestyle. This includes daily exercise, eating a healthy dose of fruits and vegetables, keeping our weight within an acceptable range for our age and height, never to start smoking, drinking minimal amount of alcohol, and learning to manage stress.

Pursuing a healthy lifestyle will help control other risk factors such as diabetes, high blood pressure and high cholesterol level. It is important to see a family physician on a regular basis and have these risk factors checked.

To pursue a healthy lifestyle is not easy or cheap. It requires significant amount of sacrifice and time commitment. It is a question of making choices. Not always easy to do that.

The volunteers with the Heart and Stroke Foundation make sacrifices and time commitment to organize fundraising events so that money can be spent on research and education to help people like me who are at a high risk for heart disease and stroke. In return we owe it to ourselves and our families to make a commitment to pursue a healthy lifestyle. Summer is a good time to do that.

Thought for the week:

“Even if we can’t be happy, we must always be cheerful.” – Irving Kristol.

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Inguinal Hernia

Dear Dr. B: I have a groin hernia. My doctor says it is an inguinal hernia. How did I get this and what is the best treatment for an inguinal hernia?

Answer: There are two types of hernia in the groin: inguinal and femoral. Inguinal hernia is by far the commonest hernia. Inguinal hernia can appear at any age – from birth (congenital) to old age (weak muscles).

The hernia appears through a potentially weak spot in the abdominal wall. The hernial sac may contain an organ, most often the bowel but sometimes the bladder or an ovary.

The hernia can be a source of discomfort or pain or can be totally asymptomatic.

A groin hernia presents as a bulge during straining, coughing, micturating or doing heavy lifting. The bulge will appear whenever there is increase in the intra-abdominal pressure. The bulge will usually disappear on lying down or after gentle manual reduction.

If the bulge cannot be reduced then it becomes a potentially life-threatening problem. The hernial contents trapped in the hernial sac may lose its blood supply and become gangrenous.

Treatment of hernia is surgery. If the hernia is causing no symptoms then one can elect not to have surgery. Hernia does not go away without surgical treatment. If surgical treatment is not undertaken then the hernia may remain the same, get bigger or there is a small risk of strangulation and gangrene.

If the hernia is symptomatic then surgery is the best answer. There are two surgical approaches to repair of inguinal hernia: open method (a groin incision with tension free mesh repair) and laparoscopic repair (done through small holes in the abdominal wall).

People commonly ask: Which method is superior? Answer to this question is controversial. Commonly four outcome measurements are used to measure the success of each technique: return to work, operative time, postoperative pain, and recurrence rate.

Studies have shown that patients return to work after a minimum of nine days, regardless of the type of repair. Return to work is more a function of employment status; self-employed workers go back to work earlier than patients on workers’ compensation.

Operative time depends on individual surgeons. Overall operative times are not significantly different between the two repairs although some studies have shown that laparoscopic repair takes little longer.

Some reports have suggested that post-operative pain is less for laparoscopic repair, but these studies have not adequately compared the patients who had open tension-free repair. What about the recurrence rate? Laparoscopic repair appears to have lower recurrence rate than open method but there were very few tension-free repairs in that study to make appropriate comparison.

Overall, the two repairs appear to have similar complication rates. The procedure is done as a day surgery under local, spinal or general anaesthetic. The type of anaesthetic used depends on the surgical technique used and the general condition of the patient.

Thought for the week:

“It’s easier to apologize than reform oneself.” – From Musings by Dennis van Westerborg, local artist and writer.

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Hemorrhoids

My doctor says I have hemorrhoids. Can you please tell me more about this subject? What is the treatment for hemorrhoids?

Answer: We all have hemorrhoids. Hemorrhoids are vascular cushions in the anal canal. External hemorrhoids are in the margins of the anal canal. Internal hemorrhoids are at the junction of the rectum and the anal canal. There are three internal hemorrhoidal cushions at three, seven and 11 o’clock.

It is important to remember that hemorrhoids are not always symptomatic and all problems in the rectal area are not due to hemorrhoids. It is difficult to estimate the true incidence of symptomatic hemorrhoids.

The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC by Hippocrates. It was thought that the hemorrhoidal symptoms were due to infection of the veins in the rectum due to passage of stool. Red-hot iron was used to cauterize the hemorrhoids!

Napoleon was finally defeated by the British at the Battle of Waterloo in 1815. Several accounts by those who were close to him have indicated that the battle was lost because Napoleon was too busy treating his hemorrhoids. He routinely treated his hemorrhoids with three to four leeches!

There are two main reasons why people get symptomatic hemorrhoids: there is a history of straining while having a bowel movement and the aging process makes the supporting tissues in that area lax. Increased intra-abdominal pressure (for example in pregnancy) and increased congenital internal anal sphincter pressure can give rise to symptomatic hemorrhoids.

Internal hemorrhoids are classified by the degree of prolapse:
-First-degree hemorrhoids do not prolapse with straining, but can be associated with bleeding.
-Second degree hemorrhoids protrude during straining but will spontaneously retract.
-Third degree hemorrhoids protrude outside the anal canal with straining and require manual reduction.
-Fourth degree hemorrhoids remain prolapsed independent of straining and are irreducible.

Patients with hemorrhoids have no symptoms or present with variety of symptoms such as bleeding, prolapse, feeling of incomplete evacuation, soiling, irritation and itching. Severe pain in the rectal area is due to thrombosed hemorrhoid, fissure or cancer.

The diagnosis of symptomatic hemorrhoids is usually made with digital rectal examination and direct visualization with an instrument. If patient presents with rectal bleeding then other causes of bleeding should be ruled out by endoscopy.

Treatment of hemorrhoids includes dietary and lifestyle changes, rubber band ligation of hemorrhoids and surgery.

High fiber diet and fiber supplement reduces the bleeding and discomfort from hemorrhoids. Fiber causes bloating and flatulence so it should be increased gradually. Avoid straining at the time of defecation. Use hemorrhoidal ointment to lubricate the anal canal before and after bowel movement.

Hot baths help relax the internal sphincter and ease discomfort in the anal area. In 1963, Barron described rubber band ligation for second and third degree hemorrhoids. After the procedure the patient may experience a feeling of pressure or rectal fullness for a period of 24 to 48 hours. There are other complications but they are rare and occur in less than three to four per cent of people.

For fourth degree hemorrhoids, surgical excision is the best option for relief of symptoms. Likely post-operative complications are pain, bleeding and urinary retention. But these treatment options are better than using leeches or red-hot iron rod!

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Vitamin B12

Dear Dr. B: What is the importance of vitamin B12? What are the causes of its deficiency?

Answer: Our body needs vitamin B12 to make blood cells. It is also important for normal function of nerve cells in the brain and the peripheral nerves.

Vitamin B12 deficiency frequently occurs in elderly people although it may also be present in the young, particularly women. It is estimated that 30 per cent of the adults older than 50 may have vitamin B12 deficiency.

Lack of vitamin B12 causes anemia and causes damage to the spinal cord and the peripheral nerves. The symptoms of these conditions may be obvious or quite subtle. Screening for B12 deficiency (by way of a blood test) is recommended in the following groups of people:
-all elderly patients who are malnourished
-all patients in institutions and psychiatric hospitals
-all patients who have blood disorders, neurological or psychiatric problems.

Vitamin B12 is an important vitamin that we usually get from our food. It is mainly found in meat and dairy products.

There are various reasons why a person is low in vitamin B12. There may not be enough of it in our diet. Especially vegetarians who do not eat meat or dairy products are at risk for vitamin B12 deficiency. But the vegetarians can get enough of it from legumes.

Quiet often the cause of B12 deficiency is not poor diet but problems with absorption in the gastro-intestinal tract.

The vitamin is absorbed through the last part of our small intestine. It can be absorbed after a protein called intrinsic factor attaches to it. Intrinsic factor is made in our stomach and attaches to vitamin B12 only if there is enough acid in the stomach.

But there are many individuals who take medication to reduce acid in the stomach in cases like gastritis, gastro-esophageal reflux disease or bacterial infection (H. pylori). These individuals are at risk of vitamin B12 deficiency if they are on these medications on a long term basis.

Pernicious anaemia is a fairly common condition in which the stomach does not have enough acid and does not make intrinsic factor normally. Absorption of vitamin B12 is also impaired in individuals who have had intestinal illness or intestinal surgery, which makes it hard for the intestines to absorb vitamin B12.

Vitamin B12 is also known as cobalamin was first isolated in 1948 and was immediately shown to be effective in the treatment of pernicious anaemia. The liver contains most of the body’s B12 (about 1.5 mg), followed by the kidneys, heart, spleen, and brain. The 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.

Treatment of vitamin B12 deficiency is by B12 injections on a regular basis for the rest of person’s life.

Thought for the week:

“Age does not protect you from love but love to some extent protects you from age.”
-Jean Moreau

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