Medicine Hat News – Page 71 – Dr. Noorali Bharwani

May 29, 2012

Gallstones can be a Source of Pain and Misery

Left – gallbladder with stones. Right – 952 gallstones from my 35-year-old male patient who presented with chelecystitis, pancreatitis and common bile duct stones.

How many gallstones does it take to get symptoms?

Just one. The size and shape of the gallstone does not matter. The more stones you have the more risk of getting symptoms. There are many patients who have gallstones and have no symptoms. These patients do not require surgery until they are symptomatic or they are moving to a country where the health care system is not very reliable.

What is the world record for the number of gallstones removed from a single gallbladder?

According to a Medical Post (October 6, 1987) clipping I have on file, two British surgeons claimed a world record for the the number of gallstones removed from a single gallbladder – 23,530. This was in an 85-year-old woman who presented with severe colicky central abdominal pain. The gallstones are now in the pathology museum at St. Thomas Hospital medical school in London, England. I wonder who counted them all.

What is my record?

On October 8, 1987 I removed a gallbladder from a 35-year-old Saskatchewan man which contained 952 gallstones (see picture). I counted these myself! The man presented with gallstone pancreatitis and jaundice. He had severe upper abdominal pain and vomitting. He also had stones in the common bile duct. This is the duct which transports bile from the gallbladder to the intestine to help us digest food.

Who is the youngest patient to have gallbladder removed for gallstones?

According to Guinness World Records, an American child, Danylle Otteni was five years and six months old at the time she had her gallbladder and gallstones removed in Philadelphia, Pennsylvania, USA, on 14 October 2007. If I remember correctly, my youngest patient was around 14 years old.

Gallstones are very common in Western countries. Probably due to our diet which is high in refined and processed food. There are other factors which can contribute to gallstone formation. But we do not know exactly why some people have gallstones. There is some chemical imbalance in the bile which precipitates cholesterol to form a nucleus for a stone. On the basis of their composition, gallstones can be divided into the following types: cholesterol stones, pigment stones and mixed stones.

The treatment for symptomatic gallstones is surgery. It is the commonest elective general surgical procedure we do.

Once, the surgical procedure of choice was open cholecystectomy. In fact, Carl 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 for symptomatic gallstones. Laparoscopic cholecystectomy was first performed in France in 1987. 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. That is called progress.

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May 22, 2012

Bob Marley and Importance of Melanoma in Darker-Pigmented Population

A case of recurrent melanoma in a Caucasian male – temple area.

I enjoy Bob Marley music. I listen to his songs quite often. As most of you know, Bob Marley was a Jamaican singer-songwriter and musician. In May 1981, he died at a very young age of 36 from melanoma. This was tragic. If he would have listened to his doctors then, who knows, he would still be around entertaining us with live performances.

In 1977, Marley was found to have malignant melanoma under the nail of one of his toes. Marley turned down doctors’ advice to have his toe amputated, citing his religious beliefs. He followed the Rastafari tradition. The spread of melanoma to his lungs and brain caused his death. Before his death, he is reported to have said, “Money can’t buy life”.

Bob Marley’s case is interesting from a medical point of view. First, melanoma is not that common in black population and secondly, melanoma under the nail (subungual) is not common either. It is an accepted fact that malignant melanoma in black population and other minority ethnic populations represents an aggressive disease highly associated with invasive lesions. They present with more advanced stage of disease at diagnosis, and consequently with a decreased survival compared with Caucasians.

Melanoma is the sixth most common cancer in North America and the single most common one among young adults 25-29 years old. Lifetime risk of developing melanoma in whites is currently estimated at 1 in 50, compared to 1 in 1000 in African-Americans.

Darker-pigmented populations are consistently reported to have lower risk for melanoma, possibly related to protection from ultraviolet radiation (UVR) provided by melanin.

Melanin is the primary determinant of skin color. It is also found in hair, the pigmented tissue underlying the iris of the eye, and other pigmented areas of the body and brain. The melanin in the skin is produced by cells called melanocytes. Some individuals have very little or no melanin in their bodies, a condition known as albinism.

Production of melanin is stimulated by DNA damage induced by UVB-radiation, and it leads to a delayed development of a tan. It is an excellent photoprotectant. This is because it efficiently absorbs harmful UV-radiation (ultraviolet) and transforms the energy into harmless heat. This prevents the indirect DNA damage that is responsible for the formation of malignant melanoma and other skin cancers.

Caucasians have a predilection to develop lesions on sun-exposed surfaces, including face and neck. Blacks have lesions predominantly located on sun-protected mucosal and acral sites.

Acral sites are the palms, soles, under the nails and in the mouth. It occurs on non hair-bearing surfaces of the body which may or may not be exposed to sunlight. Unlike other forms of melanoma, acral lentiginous melanoma (ALM) does not appear to be linked to sun exposure.

Lentiginous means small, flat, pigmented spot on the skin or under the nail. The reason these lesions have poor prognosis is because they are quite often clinically misdiagnosed.

In fact, an estimated one-third to one-half of all cases of ALM are incorrectly diagnosed at initial presentation as the more commonly appearing benign skin lesions including warts, infections, ulcers, callus, traumatic wounds, and blood clots. Some melanomas have no pigment and these are hard to diagnose early unless you notice some change.

The moral of today’s story is: be vigilant, protect against UV rays, and report to your doctor if there is any change in a mole. If you have a pigmented lesion under a nail, palm of your hands, or sole of your feet which does not go away (a blood clot will slowly disappear) then get a biopsy done. And listen to your doctor. Melanoma can be cured if picked up early.

Long live Bob Marley and his music.

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May 15, 2012

Hold Your Nose – Fecal Transplant Works

A woman pinching her nose. (iStockphoto/Thinkstock)

In my last article, I mentioned stool (fecal) transplant being an option in the management of intractable C. difficile-associated diarrhea (CDAD). Your reaction must have been, “Yuck!”

“It’s a nasty topic to discuss but fecal transplants work – and I was not ready to wait any longer.” says a 66 year-old-man from Cape Breton (The Medical Post, April 24, 2012). The man gave himself a fecal infusion to try and rid himself of a C. difficile infection after being turned down for the procedure by Cape Breton Regional Hospital. His doctor’s reaction, “He did it himself? It’s not good to do by himself.”

Stool transplant (also called fecal bacteriotherapy), a procedure related to probiotic research, has preliminarily been shown to cure the disease. The procedure involves infusion of bacterial flora acquired from the feces of a healthy donor to reverse the bacterial imbalance responsible for the recurring nature of the infection in CDAD.

Bacteria make up most of the flora in the colon and up to 60 per cent of the dry mass of feces. Somewhere between 300 and 1000 different species live in the gut, with most estimates at about 500. According to Wikipedia, it is probable that 99 per cent of the bacteria come from about 30 or 40 species. Fungi and protozoa also make up a part of the gut flora, but little is known about their activities.

What is the function of these bacteria in our gut?

Humans and their bacterial flora have a non-harmful coexistence. The microorganisms perform a host of useful functions, such as fermenting unused energy substrates, training the immune system, preventing growth of harmful, pathogenic bacteria, regulating the development of the gut, producing vitamins for the host (such as biotin and vitamin K), and producing hormones to direct the host to store fats.

In fecal transplantation, donor stool is collected from a close relative who has been tested for a wide array of bacterial, viral, and parasitic pathogens. The stool is often mixed with saline or milk to achieve the desired consistency, then delivered through a colonoscope or retention enema, or through a nasogastric or nasoduodenal tube.

The idea is to replace normal, healthy colonic flora that had been wiped out by antibiotics, and reestablishes the patient’s resistance to colonization by Clostridium difficile.

Since 1958, more than 150 papers have been published on this subject. It has a success rate of about 90 per cent. A guide was released in 2010 for home fecal transplantation. Reports from many centres suggest that fecal transplants can be lifesaving for patients with recurrent CDAD.

In November, 2010, Alberta’s Institute of Health Economics released a report (Fecal Transplantation for the Treatment of Clostridium difficile-associated disease and/or ulcerative colitis) concluded that fecal transplant may restore normal bacterial flora, break the cycle of recurrent CDAD, usually after treatment failure with vancomycin therapy.

The report said, “The status of fecal transplantation as an experimental or accepted procedure for patients with recurrent CDAD remains to be determined.”

Currently, there are numerous studies going on to compare fecal transplant with other kinds of therapy in CDAD cases. The safety of the procedure needs to be clarified. Especially, now that the procedures are carried out in people’s homes rather than in the hospitals to avoid bureaucratic battles. Hopefully, we will have a definitive answer in the next few years.

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May 8, 2012

C. difficile-Associated Diarrhea In Pregnancy – A Complex Clinical Challenge

A pregnant woman touching her belly. (Jupiterimages)

Photograph shows colon acutely inflamed – red, swollen with white patches of psuedo membranes. An extreme case of C.difficile colitis – also known as pseudomembranous colitis.

In 1935, Hall and O’Toole first isolated a bacterium from the stool of healthy newborns. They named it Bacillus difficilis to reflect the difficulties they encountered in its isolation and culture. Now, after 77 years, we are unable to contain the growth and spread of the same bacterium, renamed as Clostridium difficile.

C. difficile is a frequent cause of infectious colitis, usually occurring as a complication of antibiotic therapy. Elderly hospitalized patients and other vulnerable patients are easy victims. Then there is community acquired disease in people who have not taken antibiotics.

This is not surprising, since C. difficile has been cultured from the stool of three per cent of healthy adults and up to 80 per cent of healthy newborns and infants. Patients who are discharged from the hospital or the visitors to the hospitals and nursing homes can pick up these bugs and spread it in the community. Hand hygiene plays an important role in prevention.

There is not much information out there on C. difficile-associated diarrhea (CDAD) in pregnancy. I did find one article: Clostridium difficile-associated diarrhea: an emerging threat to pregnant women (American Journal of Obstetrics and Gynecology – June 2008). The article says that largely due to their young age and overall good health, pregnant women have historically been at low risk for developing CDAD.

In a retrospective study of 74,120 admissions to an obstetrics and gynecology service over 10 years, only 18 women (0.02 per cent) developed CDAD. However, a Morbidity and Mortality Weekly Report reported 10 cases of peripartum (occurring during the last month of pregnancy or the first few months after delivery) disease from four states. Among these women, 40 per cent required hospitalization, 50 per cent experienced relapse, and one died.

Since CDAD is not a reportable disease, it is difficult to know the exact incidence of the problem and its complications in pregnant patients. It is a serious problem and CDAD should be taken seriously in this particular population and to raise the level of concern and vigilance among physicians.

Patients with CDAD can have a broad range of symptoms. Patient may be asymptomatic carrier or in an extreme situation may have life-threatening colitis.

Approximately, three per cent of adults and 80 per cent of neonates are infected with C difficile and most remain without symptoms. About 25 to 30 per cent of hospitalized adults are also C difficile carriers. These patients do not require any treatment.

Some patients have mild-to-moderate diarrhea, usually not bloody. At the other extreme, patients can be very seriously sick and have pseudomembranous colitis (see photograph). This is a serious condition and is a systemic illness. Patients have abdominal pain and tenderness, fever, and severe diarrhea that may be bloody. Marked elevations of the white blood count can be observed and may serve as a diagnostic clue. Bowel perforation is a very serious complication.

Oral metronidazole or oral vancomycin remains first-line therapy. Use of metronidazole in pregnancy remains controversial. Oral vancomycin is the only FDA-approved medication for the treatment of CDAD and can be used in pregnancy. Probiotics, to replace the good bugs in the gut, helps. Questran powder can be used to slow down the frequency of bowel movements. For intractable cases, stool transplant is an option.

Regardless, 12 to 24 per cent of patients develop a second episode of CDAD within two months of the initial diagnosis. If a patient has two or more episodes of CDAD, the risk for recurrences increases to 50 to 65 per cent.

Clearly, CDAD and C difficile infection pose a complex clinical challenge to the physician – whether the patient is pregnant or not.

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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