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Gastroparesis

Dear Dr. B: What is gastroparesis?

Answer: It is a condition in which the muscles in the wall of the stomach do not function normally. This leads to delayed gastric emptying. Patients complain about nausea and vomiting.

Most cases of gastroparesis are mild in nature. They respond to medications. According to an article in Tech-Wise, published by Alberta Heritage Foundation for Medical Research (www.ahfmr.ab.ca), about six to 10 people per 100,000 population have gastroparesis and do not respond to conventional treatment.

In severe cases of gastroparesis, patients have severe nausea, vomiting, pain, loss of appetite and weight loss. Vomiting usually occurs several hours after eating when the stomach is full of undigested food, stomach enzymes and acid. Patient’s nutrition is poor as the food does not reach the small intestine where digestion and absorption of food occurs.

Diagnosis of gastroparesis is difficult to make as nausea and vomiting can be symptoms of many conditions. Two most common investigations used to investigate gastroparesis are barium x-rays and endoscopy of the esophagus, stomach and duodenum. These tests are not always diagnostic but are important to rule out mechanical obstruction (cancer, ulcer, scarring and narrowing of the lumen) in the upper gastro-intestinal tract. Gastro-duodenal manometry is not available in all centers and is not necessary to make a diagnosis of gastroparesis.

What causes gastroparesis?

Most often the cause of gastroparesis is not known. According to Mayo Clinic website (www.mayoclinic.com) there are many precipitating factors like diabetes, surgery to upper gastro-intestinal tract, certain types of medications, cancer chemotherapy and other medical conditions like anorexia, bulimia, scleroderma, Parkinson’s disease, other nervous system illnesses and metabolic disorders such as hypothyroidism can lead to gastroparesis. Quite often it is not possible to find a cause of gastroparesis.

Is there a good treatment?

Currently there is no cure for gastroparesis. The first line of treatment to control symptoms is dietary changes (eat easily digestible food), medications to control vomiting and stimulate gastric emptying. These measures may not be effective in every case.

Researchers are investigating other types of therapies, including a stomach “pacemaker,” that eventually may prove more effective than current treatments for gastroparesis, says the Mayo Clinic website. This is called Enterra Therapy System (ETS). This new treatment is described and reviewed in Tech-Wise (June 2006). Here is the summary:

ETS is a neurostimulator that is implanted under the skin in the abdominal wall. It provides high frequency, low energy stimulation to the stomach wall through a pair of electrodes. The device is licensed in Canada for the treatment of chronic intractable nausea and vomiting.

The article reviewed six studies. Four studies showed at six to 12 months follow up there was significant symptomatic improvement after the device was implanted. Three studies showed improvement in nutritional status and two studies reported a significant improvement of quality of life.

The review article says that these improvements were not associated with improvement in gastric emptying. The device relieves symptoms of gastroparesis but how it does that is not known. Some authors speculate that it may be a placebo effect. The article says that the device is not for routine use in cases of gastroparesis. It should be used only as a last resort when other measures fail to relieve the symptoms.

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Asthma and Reflux

Dear Dr. B: I have asthma and my doctor thinks it is caused by gastro-esophageal reflux disease although I have no history of heartburn. Can you please explain this to me?

Answer: Heartburn and regurgitation are classical symptoms of gastro-esophageal reflux disease (GERD). But GERD may present in atypical ways. Atypical presentation may be in the form of diseases of the lungs, ear, nose and throat or in some other ways. In atypical presentation, majority of the patients do not have classical heartburn or acid regurgitation.

Asthma, chronic bronchitis, aspiration pneumonia, bronchiectasis and pulmonary fibrosis may be some of the lung problems a person may have with atypical GERD.

Atypical GERD may affect ear, nose and throat in the form of chronic cough, laryngitis, hoarseness, pharyngitis and sinusitis.

Non-cardiac chest pain, dental erosions and sleep apnea are other conditions related to atypical presentation of GERD.

These patients are suspected to have atypical presentation of GERD when they fail to respond to conventional therapy for their medical condition. For example, all patients with non-allergic asthma in which wheezing is poorly controlled should be evaluated for GERD.

Studies have shown that 30 per cent or more patients undergoing cardiac angiogram for chest pain will have normal findings. Of these 40 to 50 per cent will have abnormal findings in the esophagus on endoscopy and pH monitoring.

Finding a cause for various conditions mentioned here can be frustrating. Heartburn is often absent. Endoscopy is often negative. It may be worth trying gastric acid suppression therapy using proton pump inhibitors (PPI) to see if the symptoms affecting the lungs, ear, nose and throat and other conditions are relieved by these medications. Trial of medications twice a day for two to three months may be effective.

If the patient does not respond to this therapy then the next line of investigation would be 24-hour pH study while on PPI.

So, it is not easy to come to a diagnostic conclusion when investigating patients who are suspected to have atypical presentation of gastro-esophageal reflux disease. I presume you have had thorough investigation and your doctor has made a diagnosis after taking into consideration all the results.

*****

Are you worried about getting old? Here is a joke I received from a friend:

“Sixty is the worst age to be,” said a 60-year-old man. “You always feel like you have to pee and most of the time you stand there and nothing comes out.”

“Ah, that’s nothing,” said a 70-year-old. “When you’re 70, you don’t have a bowel movement any more. You take laxatives, eat bran and sit on the toilet all day and nothing comes out.”

“Actually,” said the 80-year -old, “Eighty is the worst age of all.”

“Do you have trouble peeing, too?” asked the 60-year old.

“No, I pee every morning at 6:00. I pee like a racehorse on a flat rock, no problem at all.”

“So, do you have a problem with your bowel movement?”

“No, I have one every morning at 6:30.”

Exasperated, the 60-year-old said, “You pee every morning at 6:00 and have a bowel movement every morning at 6:30. So what’s so bad about being 80?”

“I don’t wake up until 7:00,” said the 80-year-old.

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All About Skin

Dear Dr. B: My mother tells me that I have a very beautiful skin and I should take care of it. She says skin has many important functions to keep us healthy. Is that true? What does skin really do?

Answer: Yes, your mother is right. Skin is not only the largest organ of our body but has many important functions to protect us from environment. Skin is constantly exposed to sun, wind, industrial elements and injuries.

Summer is officially here and it is a good time to remind ourselves what a good job our skin does to protect us and keep us healthy. It is an organ we take for granted. But we should know better than that.

Skin is thick and waterproof. Skin is a protector, a temperature regulator and has a very sharp sensitive device. Skin has a capacity to excrete fluid and electrolytes. It stores fat and synthesizes vitamin D when our skin is exposed to sunlight or ultraviolet rays. Skin has great absorbing capacity and it can absorb many chemicals and drugs.

It plays an important role in maintaining body temperature. When a person feels hot the blood vessels in the skin dilate and sweat secretion increases. The body loses heat by radiation from the large amount of blood circulating through the dilated blood vessels in the skin and by evaporation of sweat.

Our skin has millions of sensitive nerve endings. These nerve endings act as antennas to give us pleasure or protect us from heat, cold, pressure and pain.

Our skin is full of hair except the palms of the hands and the soles of the feet. Hair on the head grows faster, 12 mm (half-an-inch) per month or five inches a year. Hair on the rest of the body grows more slowly. Hair keeps us warm and protects us from dust and sand.
Hair is sensitive to touch.

What about nails? We have fingernails and toenails. Nails are small in size but they play an important role, serving to help protect our fingers and toes and improve dexterity. They also may reveal clues to our general health.

Sweat glands are found in almost every part of the skin. They normally release a little fluid all the time, and as this fluid evaporates, our body cools off. If we need to cool off then these glands can get stimulated to be more active. They secrete even more fluid and help us cool off more thanks to skin temperature nerve endings.

Oil glands (sebaceous glands) produce oil secretion known as sebum. The sebum spreads on the skin. It prevents excess water loss, lubricates and softens the skin and hair. It keeps the skin flexible and waterproof. Hormones control the production of sebum. Sebum is mildly toxic to some bacteria.

So, you can see how much skin can do to protect us. It is indeed an important organ. Look after it. Protect it against the damaging effects of sun, wind and harmful chemicals. If your mother thinks your skin is beautiful then she is right. You owe it to her and to yourself to look after it.

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A Beautiful Wedding

This picture shows Helena and Karim during their church wedding ceremony.

This picture shows Helena and Karim going through one of the Indian traditional wedding ceremonies.

A few days ago I was in rainy Vancouver to attend a very special wedding. It was the wedding of my nephew Karim. An Ismaili Muslim, born in Uganda and brought up in a cosmopolitan city of Vancouver. He was marrying Helena, a Catholic born in Portugal who was also brought up in the beautiful city of Vancouver. The love birds have been dating for the last two years. They got engaged a year ago.

I took my wife, my children and my mother with me. My mother lives in Calgary. She did not want to miss her grandson’s wedding. We flew from Calgary to Vancouver on a Thursday. It was a rainy Thursday.

This was a very special wedding because we have been waiting for Karim to get married for many years. We could not believe that the day had arrived. Karim’s parents had six children, including triplets. His parents came to Canada as refugees to run away from Idi Amin’s brutality in Uganda. Karim was a little boy then. As fate would have it, Karim’s mother missed the wedding. She passed away 10 years ago from pancreatic cancer. She was 60 years old.

Helena is a special lady. She is the only child of her parents. She is beautiful, youthful, vibrant, hard working and ambitious. Karim is tall, dark and handsome and they make a wonderful couple.

The wedding was planned to spread over three days. On Thursday night (the day we arrived) was a traditional mehndi (henna) ceremony. The ladies did not want to miss this. According to a web definition, henna is a coloring agent made from the green leaves of a henna plant which, when mixed with ingredients like tea, coffee, cloves, or tamarind, forms a paste. The tradition is popular in Middle East, North Africa and South Asia.

Saturday was the wedding day. The sun came out and it remained sunny for the rest of the day. The wedding took place in the afternoon at St. Augustine’s Parish. It was a good dignified wedding. Helena and Karim looked very beautiful and handsome. The families from both sides were present to witness the event. Many photographs were taken to record the event for their children and grandchildren.

The evening reception began with a traditional Indian wedding ceremony. This consists of several rituals to ward off evil and bring good luck, happiness, fertility and prosperity to the couple.

The food was excellent, a mix of eastern and western cuisines keeping in tune with the highly multicultural and multi-religious guests in the room. There were speeches, toasting, laughter and dancing until the early hours of the morning.

Karim spoke about his mother. How much he misses her. He was happy to see his grandma (now 88 years old) fly from Calgary and his older sister from Edmonton although both have to rely on wheelchairs to get around. That was very special.

Sunday was the last day to wind up the wedding ceremony. There was a family brunch and a visit to the cemetery to pay respects to Karim’s mom.

This wedding was a good example of what Canada stands for: peace and harmony among all faiths and all cultures. May Helena and Karim be blessed with a very long and happy life. With two Gods (so to speak) looking down on them, things cannot go wrong! Can they?

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