Author: noorali

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Snowbirds – Be Aware of the Risks of Blood Clots in the Legs

Fall is here. Winter will be here soon. Canadian snowbirds are heading south. This involves long hours travelling by road or by plane. Studies have shown a two- to four-fold increased risk of blood clots in the legs following air travel. Similar risk applies to travel by road. The condition is called venous thrombo-embolism (VTE).

There are several risk factors. A population-based case-control study of adults receiving treatment for their first VTE found that long-distance travel (≥4 hours) doubled the risk of VTE. The effect was greatest in the first week after travel but remained elevated for 2 months. Travel by air increased the risk to the same extent as travel by bus, train, or car, suggesting that the increased risk of air travel is due primarily to prolonged immobility.

Women who used oral contraceptives, travellers who were overweight with BMI >30 kg/m2, and those with height >1.9 m (approximately 6 ft 3 in) were at increased risk. People shorter than 1.6 m (approximately 5 ft 3 in) had an increased risk of VTE only after prolonged air travel. Cancer, dehydration and smoking cigarettes also increase the risk of VTE.

A blood clot in a superficial vein is known as superficial thrombophlebitis. This condition is usually not serious or life threatening.

A blood clot in a deep vein of a leg is known as deep vein thrombosis (DVT). This is a serious condition as the clot may dislodge, travel through the blood stream and plug a vessel in the lung (pulmonary embolism). Pulmonary embolism (PE) can be fatal.

The calf muscles act as a second pump (first pump being your heart). The contraction of the calf muscles and the valves in the deep veins help push the blood from the lower extremity towards the heart.

DVT occurs when the blood moves through deep veins in the legs more slowly than normal or when there is some condition that makes blood more likely to clot. Two common examples are: when you are bedridden (after surgery, injury or chronic illness) or when you sit still for a long time (such as during a long plane flight or a long road trip). Under these conditions the blood moves more slowly and stagnation promotes clotting.

Symptoms of DVT include swelling, redness, pain, or tenderness, and increased warmth over the skin. It may be difficult to distinguish from muscle strain, injury, or skin infection. Diagnosis is confirmed by special radiological tests. Symptoms of PE range from mild and nonspecific to acute, resembling heart attack or stroke. Once a clot has travelled to the lungs, common symptoms of PE are chest pain and shortness of breath.

There are measures you can take to prevent VTE. All travellers should keep hydrated with non-alcoholic beverages, wear loose-fitting clothing, do frequent calf muscle contraction and make efforts to walk and stretch at regular intervals during long-distance travel. Compression stockings may be beneficial to travellers with other risk factors for VTE. Currently no convincing data suggest that pharmacologic interventions reduce the risk of significant VTE during travel.

Treatment of VTE is with blood thinners (anticoagulants) like heparin and Warfarin to prevent pulmonary embolism. The blood thinners do not dissolve the clot. They stop the clot from getting bigger, prevent the clot from breaking off and reduce the chances of having another blood clot.

The body takes its own time to dissolve the clot or the clot may get organized and form scar tissue, permanently blocking the vein or damaging the valves. Normally, no tests are done to check if the clot is still present as the tests can be inconclusive or confusing.

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Case #1 – Pilonidal Disease

The pilonidal disease most commonly occurs between the buttocks, close to the tailbone. This condition has been described since 1847.

The term pilonidal means hair-nest.

It can also occur in other areas such as beard, the armpit, the belly button and the web spaces of the hands (in barbers) and feet.

The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft between the buttocks. The disease is more common in men than women and frequently occurs between puberty and age 40. It is also common in obese people and those with thick, stiff body hair.

Pilonidal disease is a spectrum of three conditions:
-acute pilonidal abscess,
-chronic pilonidal abscess or sinus,
-unhealed pilonidal surgical wound.

For many years, experts believed that this was a congenital condition. In 1946, Patty and Scarff challenged this theory and drew attention to the role of hair in the origin of this problem. Current evidence strongly indicates an acquired origin for pilonidal disease, with most infections being related to penetration of the skin by hair through small midline pits.

Example of pits and infection:
Example of pits and infection.

Where do these pits come from? Some people believe they are congenital while others believe them to be enlargement of hair follicles. These pits have sinus openings through which the hairs penetrate. Hirsutism in the buttock and perineal area appears to be associated with the development of pilonidal disease.

Management of the condition depends on the type of presentation.

Acute pilonidal abscess needs to be drained immediately once the diagnosis is made. The area should be kept shaved. Daily bath or shower will keep the area clean. Once healed, it may become necessary to excise the midline pits under local or general anaesthesia to prevent recurrence.

Treatment of chronic pilonidal abscess or sinus remains controversial as no one treatment has proved superior. The choices are:
-non-operative treatment with repeated phenol injections
-conservative excision of the sinus openings and midline pits
-laying open the sinus tract and stitch the skin margins to fibrous tissue (marsupialization)
-wide excision with or without different types of closures of the skin.

Example of wide excision:
Example of wide excision

The unhealed pilonidal surgical wound and recurrence of pilonidal disease after initial treatment is very common. Management of this problem can be very difficult. To start with, the unhealed wound should be curettaged to control the excessive granulation tissue (healing tissue which fills the wound), and the surrounding skin should be shaved weekly. The wound should be kept clean and dry with gauze. Strapping the buttocks apart may help prevent the continuous shearing movement during walking.

The wound may take six to eight weeks to heal. Quite often healing does not occur. Then a skin graft or some form of plastic flap may help the healing process.

If the wound can be closed, it will need to be kept clean and dry until the skin is completely healed.

If the wound must be left open, dressings or packing will be needed to help remove secretions and to allow the wound to heal from the bottom up.

After healing, the skin in the buttocks crease must be kept clean and free of hair. This is accomplished by shaving or using a hair removal agent every two or three weeks until age 30. After age 30, the hair shaft thins, becomes softer and the buttock cleft becomes less deep.

Overall, treating pilonidal disease should not be taken lightly as the results may be disappointing. There is no one good treatment which works for all patients with pilonidal disease

Pilonidal disease image 1
Pilonidal disease image 2
Pilonidal disease image 3
Pilonidal disease image 4
Pilonidal disease image 5

For more information visit:
-Another article on my website – Pilonidal Cyst
–American Society of Colon and Rectal Surgery
–Pilonidal disease support group

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The Role of Exercise in Some Intestinal Disorders

In 2001, Gut – An International Journal of Gastroenterology and Hepatology, published a review article from the Netherlands titled “Potential benefits and hazards of physical activity and exercise on the gastrointestinal tract.”

It is an interesting review. It says that acute strenuous exercise may provoke gastrointestinal symptoms such as nausea, heartburn, diarrhea and gastrointestinal bleeding. This happens especially during vigorous sports such as long distance running and triathlons. About 20 – 50 per cent of endurance athletes are hampered by these symptoms. This may deter them from participation in training and competitive events. But it has no long term effect on their health.

In contrast, the article says, repetitive exercise periods at a relatively low intensity may have protective effects on the gastrointestinal tract.

There is strong evidence that physical activity reduces the risk of colon cancer by up to 50 per cent. The primary postulated mechanism, according to the article, is that physical activity reduces intestinal transit time which would limit the time of contact between the colon mucosa and cancer promoting contents.

Several studies have been published on the relationship between physical activity and gall stones. Still more work needs to be done. Regular exercise may reduce the chance of developing gall stones.

A limited number of studies have investigated the preventive effect of physical activity on inflammatory bowel disease (Crohn’s disease and ulcerative colitis). The article says, “While the preventive effect of physical activity remains inconclusive, it has become clear that physical activity is not harmful for patients with inflammatory bowel disease….”

Physical activity in patients with inflammatory bowel disease should be encouraged as these patients have muscle weakness and are at risk of osteoporosis, especially if they are on steroids for the treatment of their disease.  Exercise will improve physical health, general well being, perceived stress and quality of life.

A possible role of physical activity in reducing the risk of diverticular disease has been reported in the medical literature. It has been suggested that diverticular disease was more prevalent among people with sedentary occupations than in more active occupations. An increase in colonic motor activity via hormonal, vascular, and mechanical aspects, leading to a reduction in colonic transit time, was postulated as an underlying mechanism.

Regular physical activity and exercise has shown a positive effect on reducing constipation. The review article mentions two case control studies that showed the defecation pattern of runners was “better” (less firm stools, higher defecation frequency, higher stool weight) than in inactive controls. Further research is required to confirm these findings.

In conclusion, strenuous exercise may induce gastrointestinal symptoms such as heartburn or diarrhoea, which may deter people from participating in physical activity. These symptoms are usually transient.

Physical activity, mostly performed at a relatively low intensity, may also have protective effects on the gastrointestinal tract. There is strong evidence that physical activity reduces the risk of colon cancer. Less convincing evidence is found for gall stones and constipation.

Physical activity may reduce the risk of diverticulosis, gastrointestinal bleeding, and inflammatory bowel disease, although up to now there has been little research to substantiate this. Physical activity does not interfere with the healing process in inflammatory bowel disease and will probably not reduce the risk of rectal and gastric cancer, says the article.

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There Are Many Ways To Be Physically Active

Doing the same thing over and over can create lethargy and boredom. This applies to physical activities as well. So, most people get involved in more than one kind of physical activity to keep them healthy and happy. Besides, our muscles and joints require different kinds of challenges to keep them strong and moving.

In my collection of old articles, I found a TIME magazine (June 13, 2005) which reported on a poll of 1011 adult Americans to see how many people exercise every week and the type of exercise they do. Nearly a third of North Americans are considered obese and a quarter of Americans (22 per cent of men, 28 per cent of women) admit that they virtually spend no time getting exercise in their leisure time.

The poll found most respondents do exercise every week. But the type of exercise or physical activity they do varies from taking a brisk walk (69 per cent) to bowling (seven per cent). Half the respondents admitted to being overweight. Dr. Tim Church, medical director, Cooper Institute, a fitness research centre in Dallas, is quoted in the article saying, “We have two epidemics. One is obesity, the other is physical inactivity.”

According to the TIME poll, 69 per cent take a brisk walk, 35 per cent use exercise machine, 32 per cent lift weights, 30 per cent ride a bike, 27 per cent jog or run, 22 per cent do aerobic exercise, 21 per cent swim, 19 per cent dance, 18 per cent play some kind of sport like soccer, 18 per cent go hiking, eight per cent play golf, seven per cent do yoga, seven per cent bowl.

Make sure the physical activity you enjoy is safe for you and people around you. A lot depends on your age, health and what kind of activity you are involved in. Riding bicycles is a good example. According to the National Safety Council in the U.S., there are 57 million Americans riding bicycles that range all the way from dirt bikes up to high performance 18-speed models.

An article in the Bulletin of the American College of Surgeons (October 2007) says, cycling ranks as the seventh most popular recreational activity after exercise walking, swimming, camping, fishing, exercise with equipment and bowling. Millions of cyclists occupy the same streets, paths and sidewalks as motor vehicles and pedestrians. There are statistics to show that many pedestrians and cyclists are injured by motor vehicles. About 14 per cent of the injured end up in rehab, nursing homes or die from their injuries. Riding motor bikes can be dangerous too.

Walking is a pretty simple way to exercise. But we have the lowest percentage of trips by walking of any country. We live in a modern society which encourages laziness and lack of movement. Compare ourselves to Old Order Amish, a religious sect which does not use cars and other modern transportation methods.

A study conducted by the Tennessee’s Department of Health and Exercise Science found that an average Amish man takes 18,425 steps a day, and the average Amish woman takes 14,196 steps. A typical American takes about 5,000 steps a day.

This shows what modernisation has done to us. It has made us lazy. Vagaries of the weather further encourage our laziness. Now that summer is over and weather is starting to get nasty for outdoor activities, we must start thinking of physical activities we can do indoors or safely outdoors. Make sure you are fit to do what you want to do. Then build your stamina slowly. There are numerous activities you can pick from. Keep it simple and start slowly. Talk to a professional trainer.

Have fun.

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