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Do Not Confuse Anal Fissure (Pain in the Butt) with Anal Cancer

A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)
A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)

There are various kinds of anal and rectal problems. Some are painful and some are not. Some are serious and others are a mere nuisance – if that is the right word. But all of them are a real pain in the butt – so to speak.

Anal fissure can be really painful. On the other hand, cancer of the rectum may be painless. The only way to find the real diagnosis is to see a doctor to get a good rectal examination consisting of inspection, finger examination and some sort of a scope test depending on your age and history. The important thing is to make sure we are not dealing with cancer or Crohn’s disease.

I have written about this subject before. You can check it out on my website. Today, I want to focus on the management of anal fissure. I want to emphasize that management of painful anal fissure requires a more aggressive approach than managing a “hemorrhoid itch.”

Five steps to manage acute or chronic anal fissure:

1. Make your stool well formed and bulky with a diet high in fiber. Take psyllium (Metamucil) two to four capsules per day with lots of water. This relaxes the anal muscles, helping the healing process.

2. Sit in a hot bath for 20 minutes twice a day for several days until the pain goes away. This really helps the healing process by relaxing the anal sphincter.

3. Minimize the intake of constipating painkillers.

4. Use two per cent diltiazam or nifedipine ointment inside and outside of anal canal twice a day. You need a prescription for this. This medication is associated with healing of chronic anal fissures in 65 to 95 per cent of patients.

5. What can be done if the fissure does not heal after three to six weeks? Rule out other illness of the colon and rectum. Your colon and rectal specialist will advise you on that. Surgical options for treating anal fissure include Botulinum toxin (Botox) injection into the anal sphincter and surgical division of a portion of the internal anal sphincter (partial lateral internal sphincterotomy).  Both of these are performed typically as outpatient procedures with good results and minimal of complications.

During my surgical training, I was taught if a doctor does not put a finger in the patient’s rectum then he may end up putting his foot in it. If you have rectal and anal symptoms then get that area examined well. You do not want anybody’s foot in it!

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Enjoyment of Life Leads to Longer Survival Among Seniors

Early morning - a bird relaxing. (Dr. Noorali Bharwani)
Early morning - a bird relaxing. (Dr. Noorali Bharwani)

“Old age ain’t no place for sissies,” said Bette Davis, an American actress. Keeping that in mind there is a continuous effort to improve the quality of life of seniors. Pills and more pills is not always the best way to make life of seniors healthy and functional.

A research article in the Canadian Medical Association Journal (CMAJ March 4, 2014) titled Enjoyment of life and declining physical function at older ages says, “Positive affective well-being (i.e. feelings of happiness and enjoyment) has been associated with longer survival and reduced incidence of serious illness.”

The authors of the article go on to say that their objective was to discover whether enjoyment of life also predicted a reduced risk of functional impairment over an 8-year period in a large population sample.

This was a prospective study involving 3199 men and women aged 60-years or older from the English Longitudinal Study of Ageing. The results provided evidence that reduced enjoyment of life may be related to the future disability and mobility of older people. Researchers obtained similar results when they limited analyses to participants younger than 70-years at baseline.

Studies have also shown that when seniors are having a good time their life is associated with longer survival and reduced incidence of coronary heart disease and stroke. That means if a senior is not happy then there is a decline in physical function. This predicts early death. That is not good.

The authors looked into several lifestyle parameters including whether the participants enjoy the things that they do, enjoy being in the company of others, whether they look back on life with a sense of happiness and feel full of energy on a regular basis.

After eight-year-study, the authors found greater enjoyment of life was associated with reduced risk of developing impaired activities of daily living and with a slower decline in walking speed.

Slow walking speed was considered an early marker of disability and frailty, as well as a predictor of dementia, admission to a long-term health facility and death. That does not sound good either.

After analysing their research results, the authors came to the conclusion, “Our results provide further evidence that enjoyment of life is relevant to the future disability and mobility of older people. Efforts to enhance well-being at older ages may have benefits to society and health care systems.” A CMAJ Editor’s comment on the article says the degree of enjoyment of life remains an important predictor of future functionality, indicating the power of a positive outlook on life.

The message is quite simple and clear. Growing older gracefully and in good health requires attention and work. As Bernard Baruch, an American financier said, “Old age is always 15 years older than I am.” He also said that one of the secrets of a long and fruitful life is to forgive everybody, everything, every night before you go to bed. Can we do that? Go have fun now.

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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Short Supply of Injectable Vitamin B12 Causes Distress Among Patients

"When I'm in turmoil, when I can't think, when I'm exhausted and afraid and feeling very, very alone, I go for walks." -Jim Butcher, Storm Front An unidentified walker in Kin Coulee Park, Medicine Hat, AB. (Dr. Noorali Bharwani)
"When I'm in turmoil, when I can't think, when I'm exhausted and afraid and feeling very, very alone, I go for walks." -Jim Butcher, Storm Front
An unidentified walker in Kin Coulee Park, Medicine Hat, AB. (Dr. Noorali Bharwani)

It has been nine months or more, injectable vitamin B12 (Cyanocobalamin) has been in short supply.

The obvious question is: why? According to media report, the drug maker Sandoz Canada had to close a manufacturing plant in Quebec in February 2012, to upgrade it to meet U.S. Food and Drug Administration standards. A second company found it too much to cope with the shortage and increased demand.

Here is the good news. Last week I asked Larry Legare, AHS Provincial Pharmacy Director, South Zone, about the availability of B12 injections. He said, “I have just received notification that Vitamin B12 1000 mcg/ml 1ml amp may be available as early as next month. This is earlier than we anticipated.” He added that there will be very limited stock available initially and stock may become unavailable again until sufficient supplies can be released to meet the current demand.

Legare says for many people with vitamin B12 deficiency, treatment with high-dose oral administration of vitamin B12 (1000–2000 mcg per day) is as effective as injectable (intramuscular or deep subcutaneous) administration. There are many reasons why some patients prefer or need to have monthly injections rather than take pills on a daily bases. I have covered this topic in the past in great detail. For more information visit my website.

It is estimated as many as five per cent of Canadian adults have a vitamin B12 deficiency. It is also reported that 30 per cent of the adults older than 50 may have vitamin B12 deficiency. It is estimated up to 40 per cent of the general population may be deficient in this vitamin. Sometimes figures are irrelevant, it is the people we worry about.

The most common cause is pernicious anemia. It is also common among vegans and people with celiac or Crohn’s diseases. Without vitamin B12, the body has trouble building the red blood cells that carry oxygen and allowing the brain and nervous system to function properly. The result is a feeling of chronic fatigue.

Legare says either oral or injection formulations are effective for treating B12 deficiency. The daily requirement is 2-3mcg. Dosing with intramuscular or deep subcutaneous injections of 100mcg daily for five to 10 days, then 100-200mcg monthly until levels are normalized followed by 100mcg monthly for maintenance.

High oral doses in the range of 1000 to 2000mcg daily are just as effective. It can be used sublingually (2000mcg). The benefit to sublingual vitamin B12 vs. oral is not well defined.

I am sure you have discussed your needs with your doctor. I hope help will be here soon. I wish you all the best. Stay positive (sometimes it is difficult to do that) and keep smiling (that can be difficult too). But don’t give up.

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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It Takes Three Minutes to Understand Tourette Syndrome

Skaters practicing at University of Calgary. (Dr. Noorali Bharwani)
Skaters practicing at University of Calgary. (Dr. Noorali Bharwani)

My niece’s grandson has Tourette syndrome. How much do we know about this condition?

Youtube has a three-minute video that is quite touching, simple and educational. The disorder was named after a French neuropsychiatrist, Gilles de la Tourette, who successfully assessed the disorder in the late 1800s. Males are affected about four times more often than females. There is usually a family history of tics.

The syndrome becomes evident in early childhood or adolescence between the ages of two and 15. It is manifested by multiple muscle and/or vocal tics lasting for more than one year. The presentation is usually involuntary (outside one’s control). It involves movements (tics) of the face, arms, limbs or trunk. The symptoms may be complicated, involving the entire body, such as kicking and stamping.

Verbal tics (vocalizations) are manifested by grunting, throat clearing, shouting and barking. The individual may suffer from coprolalia (the involuntary use of obscene words or socially inappropriate words and phrases) or copropraxia (obscene gestures). Others may repeat word of others (echolalia), repeating ones own words (palilalia), and repeating movements of others.

Fortunately most individuals with Tourette’s syndrome have mild symptoms. Some may have associated conditions like attention problems, obsessional compulsive behavior, and learning disabilities. For most, there are no barriers to achievement in their personal and professional lives. Persons with Tourette syndrome can be found in all professions.

There is no specific treatment or preventative measure. Tourette Syndrome Foundation of Canada (TSFC) has an educational website worth visiting. The goal is to educate both patients and the public of the many facets of tic disorders. Increased public understanding and tolerance is important to people with Tourette syndrome and their families.

This reminds me of a story I read somewhere.

David, a second-grader, was bumped while getting on the school bus and suffered a two-inch cut on his cheek. At recess, he collided with another boy and two of his teethe were knocked loose. At noon, while sliding on ice, he fell and broke his wrist. Later at the hospital, his father noticed David clutching a quarter in his good hand. “I found it on the ground when I fell,” David said. “This is the first quarter I ever found. This sure is my lucky day.”

In a small or big way, we are all blessed with something good. So keep smiling.

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