Dr. Noorali Bharwani

March 22, 2011

Is Anal Itch Driving You Crazy?

Dear Dr. B: Anal itch is driving me crazy. I have used all kinds of stuff bought over the counter but nothing seems to help. What should I do?

Answer: I have covered this subject before but it is worth going through this again. The number of people who have this problem is amazing. It all boils down to spending little extra time and taking care of that area. Most of us take care of our mouth by regularly flossing and brushing, getting a dental check and seeing a dental hygienist on a regular basis. But we do not do all that for our rear end. Why? A finger is scarier than a dentist’s drill?

Anal itch or some people may call it rectal itch is also known as pruritus ani (proo-rí-tus a-ní). It is a fairly common condition. Most people think that the reason they cannot stop scratching their butt is because of hemorrhoids. But there is more to itchy butt than you think.

There are several benign conditions which can cause anal itch. Conditions to keep in mind are hemorrhoids, fecal incontinence of varying magnitude and severity, anal fistulae (leaking pus and stool) and condylomata (anal warts). Anal fissures are very painful but may be a cause of anal itch in chronic cases.

Other benign conditions which can cause anal itch are contact dermatitis, fungal infections, diabetes, pinworm infections, psoriasis and seborrhea (dermatitis of the oil glands).

A common cause of anal itch is excessive moisture in the area. Moisture may be due to perspiration or a small amount of residual stool around the anus. Itching can be made worse by scratching, vigorous cleansing of the area or overuse of topical treatments. Use of dry rough toilet paper can be another source of itch. You might as well use sand paper (just kidding!).

In some individuals, itching can be caused by eating certain foods, smoking and drinking alcoholic beverages, especially beer and wine. Examples of food items associated with anal itch are coffee, tea, carbonated beverages, milk products, tomatoes and tomato products such as Ketchup, cheese, chocolate and nuts. That is hell of a list. If you are over indulging in any of these items then you may know where the problem lies.

Cleanliness is next to godliness, so once a person develops the itch there is a tendency to wash the area vigorously and frequently with soap and a washcloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils. God will not be happy with that.

What about cancer? Yes, we have to keep that condition in mind. You may recall, Farrah Fawcett, one of the Charlie’s Angels, was diagnosed with anal cancer in 2006. Subsequently she died from that condition.

If you have anal itch, then talk to your doctor and get the area thoroughly checked.

Treatment depends on the cause of the problem. Besides that there are things you can do. Try dietary modifications. Avoid moisture in the anal area by using cotton balls, gauze or corn starch powder. Avoid further injury to the area by avoiding soap of any kind and do not scrub the area. For hygiene, it is best to rinse with warm water and pat the area dry. Use wet toilet paper, baby wipes or a wet washcloth to blot the area clean. Never rub.

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March 15, 2011

Irritable Bowel Syndrome a Significant Problem for Some

Irritable bowel syndrome (IBS) is the most common chronic intestinal disorder. The symptoms are due to disturbance in the movement and sensation of the bowel. The person is otherwise well but presents with chronic or recurrent abdominal pain, change in bowel habit (constipation and/or diarrhea) and bloating.

Literature suggests at least 15 percent of the population has this condition. I feel that almost everybody has some element of irritable bowel syndrome.

IBS affects twice as many women as men and usually begins in early adult life. Although IBS can cause much distress, it does not lead to life-threatening illness. It is also called spastic colon. IBS is not like other conditions. There are no definite abnormalities to find in a patient with IBS and there are no tests to confirm the diagnoses.

IBS is a complex condition that affects a person’s psychology (emotional and behavioural characteristics). A physician treating this condition must have a good understanding of the problem. He should be able to dedicate time and energy to help his IBS patients.

IBS is considered to be a functional disorder of the gastrointestinal tract. But there is high incidence of psychiatric disorders in patients with IBS – panic disorder, major depressive disorders, and phobias.

Patients have to realise that they may need psychological treatment for a physical condition. And having irritable bowel does not mean a person is mentally ill. Antidepressants and medications that inhibit anxiety have been shown to be effective in IBS. But these drugs have to be used with care.

Stress-induced anxiety can make symptoms of IBS worse. The source of stress can be internal (from within your own body) or external (from your environment). IBS patients experience higher levels of anxiety and fatigue than do healthy people.

Management of IBS can vary from simple to complex. First, you have to see a doctor and get some basic investigations done to rule out any other illness like infection in the bowel, cancer, ulcerative colitis, Crohn’s disease and celiac disease. Anemia, rectal bleeding and loss of weight are not symptoms of IBS. This may suggest inflammatory bowel disease (IBD) or cancer of the bowel.

There is no cure for IBS. However, controlling the diet and emotional stress usually relieves the symptoms. Sometimes symptoms come and go. Some medicines may also help.

In more severe cases, like treatment-resistant IBS, psychotherapy has been proven to be useful. But there is no evidence to suggest that psychotherapy is beneficial in patients with mild IBS.

Management of IBS poses a big challenge to a physician. Many drugs are available in the market for use in IBS. But none of them have proven benefits. Some of them may act as placebo. Smooth muscle relaxants tend to help relieve abdominal pain with or without relief of other symptoms. Loperamide (Imodium) is beneficial in patients who have diarrhoea as a predominant symptom. Psyllium and other higher fibre diets are useful for patients with constipation.

Current treatment of IBS includes advice on high fibre low fat diet, smooth muscle relaxant, agents to stop diarrhoea or bloating and psychotherapy or psychoactive drugs to take care of depression or anxiety.

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March 1, 2011

A New Blood Thinner for Patients with Irregular Heart Rhythm

About 250,000 Canadians suffer from irregular heart rhythm called atrial fibrillation (AF). In the U.S. there are approximately 2.3 million adults with AF. Older you are, higher the risk of developing this condition. Some heart problems and medical conditions can put you at a higher risk.

Most dangerous complication of AF is stroke. It accounts for up to 36 percent of all strokes in elderly people. The cost of looking after patients with stroke runs into millions of dollars.

To prevent this, patients with AF are converted to regular (sinus) rhythm by applying direct-current electrical shock (cardioversion), by medications or by ablation therapy. If it is difficult to sustain regular rhythm, then the patients receive blood thinners (like warfarin) on a regular basis to reduce the risk of stroke by 70 percent. Warfarin, as you may know, is a rat poison.

Main advantage of warfarin is that it is cheap and is covered by provincial drug plan. Major disadvantages are that you need frequent blood tests to make sure that the blood concentration of the drug is at a safe level to keep the blood thin but not dangerous enough to make you bleed in the brain or some other place. It is quite difficult to achieve the safe level and maintain it. The blood levels fluctuate when you eat certain kinds of foods or take other medications. So there is always some level of anxiety and uncertainly when you are on warfarin.

Now, here is the good news. In the last few weeks, the Canadian Cardiovascular Society issued new guidelines for prevention of stroke in patients with AF by recommending that patients at high risk of stroke be prescribed the new blood thinner dabigastran (Pradax) instead of warfarin. The new drug has fewer side effects and requires no blood tests. But it is not covered by provincial drug plans.

In a study published in the New England Journal of Medicine (September 17, 2009), the authors report that the rate of major bleeding was 3.36 per cent per year in the warfarin group, as compared with 2.71 per cent per year in the group receiving 110 mg of dabigastran twice a day and 3.11 per cent if you are on 150 mg dabigastran twice a day.

The rate of stroke due to bleeding in the brain was 0.38 per cent per year in the warfarin group, 0.12 per cent in the 110 mg dabigastran group and 0.10 per cent in the 150 mg dabigastran group.

The death rate was 4.13 per cent in the warfarin group, 3.75 per cent in 110 mg dabigastran group and 3.64 per cent per year in 150 mg dabigastran group.

The authors conclude by saying that if you switch over to 110 mg dabigastran twice a day from warfarin then the risk of stroke would be similar to warfarin but lower rate of major bleed.

If you switch over to 150 mg dabigastran twice a day then compared to warfarin, you will have lower risk of stroke but similar risk of major bleed as warfarin.

Dabigastran (Pradax) is made by Boehringer Ingelheim and more information is available on their website: www.boehringer-ingelheim.ca.

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February 27, 2011March 12, 2017

Case 2 – Neurofibromatosis

Ten things you should know about this condition: (photos at bottom)

1. Neurofibromatosis (von Recklinghausen disease) was first described in 1882 by the German pathologist, Friedrich Daniel von Recklinghausen (December 2, 1833-August 26, 1910).

2. Neurofibromatosis (also known as von Reklinghausen disease) is a genetically-inherited disorder in which the nerve tissue grows tumours (neurofibromas) that may be benign or may cause serious damage by compressing nerves and other tissues.

3. They develop disordered skin pigmentation and “cafe-au-lait” spots.

4. The tumours may cause bumps under the skin, coloured spots, skeletal problems, pressure on spinal nerve roots, and other neurological problems.

5. Neurofibromatosis is an autosomal dominant disorder, which means that it affects males and females equally and is dominant (only one copy of the affected gene is needed to get the disorder). If only one parent has neurofibromatosis, his or her children have a 50 per cent chance of developing the condition. In about 50 per cent of cases there is no other affected family member because a new mutation has occurred.

6. There are two types of neurofibromatosis: type 1 (90 per cent) and type 2 (10 per cent). Neurofibromatosis-1 is found in approximately 1 in 2,500-3,000 live births.

7. Major symptoms are often due to involvement of optic (blindness) or acoustic (deafness) nerves or the spinal cord. Less than 3 per cent of the tumours can turn into cancer – such as neurofibrosarcomas.

8. There is a high incidence of learning disabilities or cognitive deficit.

9. There is no cure for the condition itself. Surgery may be needed when the tumours compress organs or other structures.

10. Joseph Merrick, the Elephant Man, was once considered to have been affected with neurofibromatosis type I. However, it is possible that Merrick suffered from the very rare Proteus syndrome. This however has given rise to the common misconception that Neurofibromatosis and “Elephant Man Disease” is one and the same (Wikipedia).

Case 2, Image 1