Posts

Posted on

Exercise With Care

Dear Dr. B: My friend and I go to a gym regularly. At the end of a strenuous session my friend feels nauseated. What is the reason?

Answer: Regular exercise has many benefits. Those benefits are achieved if the exercise is done properly. Otherwise, exercise may harm you. Let us try and understand what happens when we exercise.

Exercise considerably increases muscle metabolism (break down of substances to yield energy). To meet this increased metabolic activity, muscles require more nutrition and more oxygen. Blood carries nutrition and oxygen to the muscles. That means more blood is pooled to the muscles at the expense of other vital organs.

The body responds to this need immediately. The body ensures that the metabolic needs of exercising muscles are met, that hyperthermia (overheating) does not occur, and that blood flow to essential organs is protected.

This protective mechanism is achieved by the circulatory system (heart and blood vessels). It involves a complex series of adjustments resulting in a large increase in cardiac output (blood flowing out of the heart) proportional to the increased metabolic demands. The increased metabolic activity rapidly increases the heart rate.

During a tough workout in a hot environment, the body can lose two liters of fluid per hour through sweat. There is also loss of electrolytes. This can result in severe dehydration which can be dangerous.

Hyperthermia can be a problem as well. It causes lightheadedness, nausea, headache, hyperventilation, fatigue, and loss of concentration. Heatstroke is the most dangerous complication of hyperthermia.

Those who use anabolic steroids to stimulate production of muscle tissue are also at an increased risk of complications.

What are the other dangers of strenuous exercise?

Heart attack and sudden death from strenuous exercise has been reported. One American report says that an estimated 1.5 million heart attacks occur every year; of these, 75,000, or about five percent, occur after heavy exertion, leading to 25,000 deaths.

Strenuous exercise or high-impact aerobics can cause injuries to bones and muscles.

High-impact exercise can also damage the inner ear, causing dizziness, ringing in the ear, motion sickness, or loss of high-frequency hearing.

The risk factors which are associated with complications during exercise are age, presence of heart disease and intensity of exercise.

How can you exercise safely?

Most important thing is to listen to warning signs. It is estimated that at least 40 percent of young men who die suddenly during a workout have previously experienced, and ignored, warning signs of heart disease: irregular heartbeat, undue shortness of breath, chest pain and weakness.

Be careful to warm up, cool down, and stretch; flexibility is the key to preventing many muscle strains. Vary training and alternate easy and harder workouts.

Don’t eat two hours before vigorous exercise. Drink plenty of fluids before, during, and after a workout. Adjust activity according to the weather and reduce it when fatigued or ill.

When exercising, listen to the body’s warning symptoms, and consult a physician if exercise induces chest pain, irregular heartbeat, undue fatigue, nausea, unexpected breathlessness, or light-headedness.

My advice to your friend is to review his exercise regime, listen to body’s warning signs and symptoms and consult a physician.

Finally, it is February. It is Heart Month. Today is Valentine’s Day. Let me wish you all a Happy Valentine’s Day. Take care of your own hearts and the hearts of your loved ones! And support Heart and Stroke Foundation.

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

Posted on

Flexible Sigmoidoscopy Should Be Encouraged

“Flexible Sigmoidoscopy Should Be Encouraged”

I would like to comment on the two reports from Baltimore on the subject of colonoscopy as a screening tool (“Symptoms not enough to predict women’s colorectal CA,” and “Colonoscopy screening: specialists walk the talk,” the Medical Post, Nov. 4, 2003).

One was a large retrospective study done by Dr. Radhika Srinivasan of the University of Pennsylvania Medical Centre in Philadelphia.

Dr. Srinivasan said most symptoms of colorectal cancer are poor predictors for the presence of the disease. Since colon cancer can occur without any symptoms, Dr. Srinivasan recommends screening colonoscopy for men and women over the age of 50.

The second study was by Dr. Prem Chattoo of St. Vincent’s Hospital in Manhattan, New York. His study showed 70% of gastroenterologists older than 50 years have had a routine screening colonoscopy, compared to about 15% of patients age 50-plus in the general population.

This finding is not surprising. We know screening for colorectal cancer saves lives. But the ideal method of screening remains controversial. Dr. Chattoo’s finding suggests the general public and the referring physicians are still not convinced an asymptomatic person over 50, with no risk factors, needs to undergo screening colonoscopy.

In Canada, my impression is the percentage of asymptomatic patients, at average risk for colorectal cancer undergoing screening colonoscopy, is probably less than 15%. Although colonoscopy remains the gold standard for screening, it is not without disadvantages.

There is a fair amount of waiting before a patient can get in for a consultation. Then there is more waiting before the patient gets a procedure. In the meantime, the patient wonders whether he has cancer or not.

Colonoscopy is as good as the skill and patience of the operator. There is a small risk of bleeding and perforation. Some patients react adversely to sedatives used during the procedure.

Endoscopy time in a hospital setting is at a premium and takes up a significant amount of hospital resources. There is a fair amount of inconvenience to patients and their families before and after the procedure (bowel prep, taking time off work, getting a ride to and from hospital, etc.). There is a great amount of anxiety about the procedure and waiting for the results.

It is estimated colonoscopy costs our health-care system about $1,000 per procedure. Eighty-five per cent of colonoscopies are usually normal and 95% of colonoscopies do not show any cancer.

Gastroenterologists and other GI endoscopists (I used to be one) are keen on promoting colonoscopy as a screening procedure. But somehow, either there is a credibility gap or there is failure in communication. Or there is no convincing argument that screening colonoscopy is as good as screening mammography or Pap smear.

What about symptomatic patients? Do all patients with lower GI symptoms need colonoscopy? Are there other tools that can be used safely and appropriately?

Flexible sigmoidoscopy is a good instrument for symptomatic patients under the age of 40 or even 50 if their symptoms are hemorrhoidal in nature. Patients younger than 40 have an incidence of colorectal cancer anywhere from 1% to 6%. Overall, for an average risk patient the lifetime risk for developing colorectal cancer is 5%.

Flexible sigmoidoscopy has many advantages. It is being underused and undervalued by many endoscopists and physicians. It is safer than colonoscopy. It is easy to perform in an office setting and does not require hospital resources. It is highly sensitive within the distance.

It is a good test for younger patients especially those who have symptoms related to the ano-rectal area. It is a good test for older patients at low risk for colorectal cancer. It is a useful test for reducing the waiting list for colonoscopies. It will make room for symptomatic patients who really need colonoscopy on an urgent basis for whom sometimes it is impossible to find a spot.

Most endoscopists find it easier to book patients for colonoscopy in a hospital than to do a flexible sigmoidoscopy in an office. This is quite a natural process as most endoscopists spend more time in hospital looking after sick patients.

Besides, to buy and maintain a flexible sigmoidoscope in an office requires a fair amount of investment for equipment and staffing. Naturally, the overhead goes up. Hence there is no incentive for physicians to set up a system in the office.

I have been doing flexible sigmoidoscopy in my office for the last 13 years or so. I think flexible sigmoidoscopy should be encouraged and promoted as a good test for many patients. Better fee schedule for the procedure would certainly help. —Dr. Noorali Bharwani, Medicine Hat, Alta.

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

Posted on

Anal Fissure

Dear Dr. B: I have painful bowel movements. I also bleed rectally. I thought I have hemorrhoids. But I have been told I have a fissure. What is a fissure? How did I get it? How can I get rid of it?

Many of the patients who are evaluated in the office for hemorrhoidal problems have in fact other conditions. It is important to remember that all anal or rectal symptoms are not due to piles or hemorrhoids.

Anal fissure (fissure-in-ano) is a painful condition. It can be confused with hemorrhoids. Uncomplicated hemorrhoids should not be painful. Hemorrhoids can be a nuisance but not painful unless they are thrombosed (have a blood clot) or are strangulated.

What is a fissure?

Chronic anal fissure is a tear in the lower half of the anal canal. There is a disruption of the skin at the entrance of the anus. The condition was first recognized in 1934. Ninety percent of the fissures are at six o’clock position (posteriorly).

Many patients with chronic fissure develop a sentinel skin tag and a little growth of tissue (hypertrophied anal papilla) inside the anal canal.

How does one get a fissure?

The exact cause of anal fissure is hard to define. Injury due to passage of a large or hard stool is thought to be the common initiating factor. But it is not always possible to get this history from patients who have a fissure. Some get a fissure after a bout of diarrhea.

Patients who have a fissure have a high resting pressure in the anal canal – that means the anal sphincter muscle tone is much higher than those who have no fissure. This high pressure causes reduced blood supply to the sphincter muscle at six o’clock position. Passing hard stool through a sphincter with high muscle tone can cause a tear in the lining of the sphincter.

The tear causes pain and further increases the spasm in the sphincter and perpetuates the problem. Patients are afraid to have a bowel movement. The more they delay the bowel movement the worse it gets as the stool gets drier and harder.

Fissures can occur in patients with Crohn’s disease and HIV/AIDS.

What is the treatment?

Treatment can be medical or surgical.

Medical treatment can heal the fissure in about 50 to 60 percent of patients. The treatment involves:

-Hot bath two to three times a day.
-Use of psyllium fiber supplements (Metamucil or Prodiem) to keep the stool soft and bulky.
-Use of ointment to relax the anal sphincter. This reduces the resting anal pressure and improves blood supply to the sphincter and allows the fissure to heal.

Glyceryl trinitrate ointment has been shown to be effective for anal fissures, but it causes headaches in a significant number of patients.

Newer treatments with fewer expected side effects include diltiazem, nifedipine, and injection of botulinum toxin. Others have tried nitric oxide, anal dilatation and hyperbaric oxygen. None of these treatments provide 100 percent cure rate. Each has advantages and disadvantages.

About 30 percent of patients will have recurrence of fissure after medical therapy.

Surgical treatment is offered to those who do not respond to medical treatment or who have frequent recurrences. The surgery of choice is lateral internal sphincterotomy (division of anal sphincter).

The surgical procedure is associated with minor continence alterations in a minority of patients. Rate of recurrence of fissure after surgery is small – three percent in one series.

How can I prevent getting a fissure in the future?

The quality and quantity of stool passing through the anal sphincter is important. It should be soft, bulky and dry. Chew your food well. Eat fruits and vegetables. Use of psyllium helps. And relax when you have a bowel movement.

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

Posted on

How Can I Stop Smoking?


Not what we have, but what we use;
Not what we see, but what we choose;
These are the things that mar or bless
the sum of human happiness.
-Joseph Fort Newton

Recently, I was pleased to read that Premier Ralph Klein is planning to quit smoking. He says his grandchildren want him to give up the bad habit.

As we know, Klein is a determined man. Once he decides do something, he does it. He stopped drinking and he received praise from all over Canada. He set a good example.

Klein may be aware that tomorrow is the first day of National Non-smoking Week. And next Wednesday is Weedless Wednesday. Wouldn’t it be nice, if during the next seven days, Klein goes public with a statement that he has given up smoking?

Klein is a very respected and successful politician. And I know one of these days, when he is ready, we will here the good news. And it will be a good present for his grandchildren.

Why it is so difficult for Klein and millions of others to quit smoking?

Nicotine is an addictive drug. It causes dependence and tolerance. Once you are hooked on it, it takes control of your mind and body. There is craving for more and more nicotine.

If you try to deprive your mind and body of nicotine then you get very unpleasant withdrawal symptoms. These are: irritability, anger, impatience, restlessness, difficulty concentrating, insomnia, increased appetite, anxiety and depression.

Smoking is also habit forming. It becomes part of our routine – cigarette on waking up, cigarette after a meal, cigarette with a drink, cigarette with coffee, cigarette before a bowel movement, cigarette after sex (remember Austin Power joke?), cigarette to relieve stress and so on.

Is there help for people who want to quit smoking?

Sure, there is help. The world does not come to an end the day you stop smoking. In fact, a whole new world opens up.

One can successfully quit smoking:

1. If the person is motivated.
2. If the person seeks counseling.
3. If the person goes on nicotine replacement therapy.

As a caring society, we can only create awareness and support system to help people quit smoking. But in the end, the success or the failure depends on personal motivation.

What motivates people to quit smoking?

There is fear of disability and death due to cancer or heart disease. There is desire to be healthy. There is a desire to have better old age, desire to be a role model for one’s family, desire to save money and use it for healthier activities, and desire to prevent damage to the environment and one’s family from second hand smoke.

What really works?

Studies have shown that self-motivation, counseling and nicotine replacement therapy achieves the highest rate of success, 40-60 percent in the initial phase and about 30 percent at the end of one year.

Nicotine replacement therapy is available in different preparations – gum, skin patch, nasal spray and vapor inhaler.

We also need to create a good support system – at home, at school and in the community.

We know that smoking is harmful. But people do start smoking and continue to smoke. Most smokers start before the age of 20, out of curiosity and from peer pressure (to look cool!).

Unfortunately, 50 percent of smokers will die prematurely due to smoke related disease. They will certainly be missed by their friends and families.

But it is never too late. You can quit smoking and reverse the damage. Help is only a phone call away.

You can see your family physician. He can help. You can also contact Rita at Freedom from Smoking (phone: 502-8224). She has plenty of tricks to share with you. But first, you should have the motivation and desire to quit smoking! Then make the phone call.

National non-smoking Week (January 18-24) is a good week to call. Good luck!

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