Tag: clinicalphoto

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What are the Long Term Consequences of Untreated Heartburn?

An empty operating room. (Hemera)
An empty operating room. (Hemera)

A case of hiatus hernia with severe reflux esophagitis - inflammation and ulcerations.
A case of hiatus hernia with severe reflux esophagitis – inflammation and ulcerations.

Heartburn is a symptom of gastroesophageal reflux disease (GERD). That means there is reflux of acid and bile from the stomach and duodenum into the esophagus. This irritates the esophagus and causes symptoms in the short term and damages the esophagus in the long run. Reflux may be associated with or without a hiatus hernia.

Children and adults are affected by this condition. Today, we will talk about adults with heartburn.

The most common symptoms of GERD are: heartburn, regurgitation and trouble swallowing. Less common symptoms are: pain with swallowing, increased salivation (also known as water brash), nausea and chest pain.

A person can have several other atypical symptoms associated with GERD. These symptoms are: chronic cough, laryngitis (hoarseness, throat clearing), asthma, erosion of dental enamel, dentine hypersensitivity, sinusitis, damaged teeth and pharyngitis.

If GERD remains untreated then there are serious consequences leading to injury of the esophagus. You don’t want that to happen to the only organ which carries food from your mouth to the stomach.

The damage starts with the condition called reflux esophagitis (see attached picture). Gastric acid and bile are toxic to the lining of the esophagus (epithelium) causing ulcers near the junction of the stomach and esophagus. This eventually leads to esophageal strictures – the persistent narrowing of the esophagus. It becomes difficult to swallow solid food and sometimes liquids if it is too narrow.

The next change occurs in the form of Barrett’s esophagus called intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus. This is a premalignant condition. The final chapter in this ongoing saga is headlined with that ugly word – cancer. What starts with a simple symptom of heartburn can transform into cancer. The progression is slow but can be persistent if heartburn is not treated.

Heartburn is a very common condition. Four to nine percent adults have heartburn daily, and another 10 to 15 percent have heartburn at least once a week. That means about 20 percent of the adults have heartburn on a weekly basis. Diagnosis is based mainly on symptoms.

Endoscopy is required if complications of GERD are suspected. Barium studies are also indicated in some instances.

Heartburn can be prevented by change in lifestyle: lose weight, change eating habits, avoid bending or straining, sleep with the head of the bed elevated (maximum damage to the esophagus occurs at night), no smoking, no alcohol, and take appropriate medications to neutralize or reduce acid in the stomach. Surgery is also an option in patients with intractable problems or complications of reflux.

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There Isn’t One Best Treatment for Sleep Apnea

A man with sleep apnea using a CPAP machine. (iStockphoto)
A man with sleep apnea using a CPAP machine. (iStockphoto)

Noorali demonstrating CPAP

There are two main goals to be achieved when it comes to treating sleep apnea. First, to establish adequate ventilation. When you stop breathing your ventilation system stops. Second, to make sure your body gets enough oxygen.

There are three ways to treat the problem. Each treatment method has advantages and disadvantages. The treatment involves behaviour modification, medical treatment and sometimes surgical treatment.

For mild cases of sleep apnea, the treatment often starts with behavioural therapy. Counselling for behavioural changes includes losing weight and avoidance of alcohol, sleeping pills and sedatives. These pills relax throat muscles, contributing to the collapse of the airway at night.

Most patients snore sleeping on their back. These patients should be asked to train themselves to sleep exclusively on their side. One way to do this is by sewing three or four tennis balls at the back of an old shirt. Wear the shirt when you go to bed and you will never sleep again on your back. It will be painful. It works and it is cheap. This can prevent the tongue and palate from falling backwards in the throat and blocking the airway.

The medical management of sleep apnea uses continuous positive airway pressure (CPAP) or dental appliance.

For moderate to severe sleep apnea, the most common treatment is the use of a CPAP. CPAP is delivered through a mask to be worn when a sleep.

CPAP keeps the patient’s airway open during sleep by means of a flow of pressurized air into the throat. The patient wears a plastic facial mask (see picture), which is connected by a flexible tube to a small bedside machine. The CPAP machine generates the required air pressure to keep the patient’s airways open during sleep. The machine can humidify the air and keep it warm.

CPAP therapy is extremely effective in reducing the episodes of apnea. But some patients find it uncomfortable. The mask is not easy to fit your face and it is not easy to sleep with. One study demonstrated 46 per cent of patients used CPAP for more than four hours per night for more than 70 per cent of the observed nights. Others have adapted to CPAP quite nicely. Some studies have shown improved survival in patients who use CPAP.

Oral dental appliance has been promoted as a useful alternative to CPAP. It is a custom-made mouthpiece that shifts the lower jaw forward, opening up the airway. There are a variety of appliances. The appliances are worn only during sleep and are generally well tolerated. Not all patients have clinically proven response. It is considered as a second line of treatment compared to CPAP.

Surgical treatment for snoring and obstructive sleep apnea has become quite popular. Probably due to the inconvenience of CPAP and oral appliance. Surgery is considered if only other methods fail. Several surgical procedures are available, each one with advantages and disadvantages. These procedures are done by Otolaryngologists (specialists in ear, nose and throat surgeries).

There isn’t one solution to the problem of snoring and obstructive sleep apnea. Weigh your options carefully. Have yourself checked out at a sleep clinic and talk to a specialist in sleep disorders. Until then happy snoring.

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Anal Cancer Can be Misdiagnosed as Hemorrhoids

Anal Cancer

You may recall, Farrah Fawcett, one of the Charlie’s Angels, was diagnosed with anal cancer in 2006. Three years later she died.

There is no need to panic. Anal cancer is fairly uncommon. It accounts for about one to two per cent of gastrointestinal cancers. About 4,000 new cases of anal cancer are diagnosed each year in the U.S.A., about half in women. Approximately 600 people will die of the disease each year.

In Canada, incidence of anal canal tumours is approximately 515 cases per year with annual incidence rate of 1.3 per 100,000 population. Review of cancer registry by researchers has shown that the incidence of anal cancer in Canada is increasing.

Anal cancers can be just outside the anus (perianal) or inside the anus. The anal canal extends from the anal verge to the upper border of the anal sphincters, and is approximately four to five cm in length. The skin for a five cm radius around the anal verge is called the perianal skin or anal margin.

What are the risk factors for developing anal cancer?

We do not know the exact cause of most anal cancers. But we know certain risk factors are linked to anal cancer. Most people with anal cancer are over 50 years old. Having anal warts significantly increases the risk. Anal warts are caused by infection with the human papilloma virus (HPV).

Persons who participate in anal sex are at an increased risk. Use of condoms is highly recommended to reduce the risk. Harmful chemicals from smoking increase the risk as well. People with weakened immune systems, such as transplant patients who must take drugs to suppress their immune systems and patients with HIV (human immunodeficiency virus) infection, are at a somewhat higher risk.

People with long-standing anal fistulas or open wounds are at a slightly higher risk. People who have had pelvic radiation therapy for rectal, prostate, bladder or cervical cancer are at an increased risk.

What are the symptoms of anal cancer?

Mostly they are no different than symptoms of hemorrhoids. That is why patients should stop saying, “Doctor, my hemorrhoids acting up again.” When you see your doctor, say what symptoms you have and let him/her make the diagnosis.

Most patients will complain about bleeding, itching, feeling of a lump, may have pain, narrowing of stools, discharge and staining of underwear and in advanced cases there may be enlarged groin lymph glands.

Biopsy is required to confirm the diagnosis. Treatment of anal cancer depends on the extent of the problem and may include surgery, radiotherapy and chemotherapy. Anal cancer can be prevented or picked up in early stages by eliminating the risk factors mentioned earlier and having your butt checked out on a regular basis. Follow the protocol for screening for anal, rectal and colon cancer. For more information, visit my website: www.nbharwani.com.

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Overactive thyroid can affect your eyes.

According to Thyroid Foundation of Canada website, it is estimated that 200 million people in the world have some form of thyroid disease. One in every three Canadians (about 10 million people) has a thyroid disorder. Of those, as many as 50 per cent are undiagnosed.

The normal function of the thyroid gland is to secrete hormones. These hormones have multitude of functions and are vital to metabolism in adults and for normal growth and development of children.

Underactive thyroid (hypothyroidism) causes many symptoms like weight gain, lethargy, cold intolerance, menstrual irregularities, depression, constipation and dry skin. Deficiency of thyroid hormone in children leads to dwarfism and mental retardation.

Overactive thyroid (hyperthyroidism) results in palpitations, nervousness, tremor, heat intolerance, weight loss, muscular weakness and usually there is a presence of goitre.

Hyperthyroidism can be caused by a number of conditions, including Graves’ disease, toxic adenoma, Plummer’s disease (toxic multinodular goitre) and thyroiditis.

Graves’ disease accounts for at least 90 per cent of all patients with hyperthyroidism. It is a condition where eyes are affected. A condition called exophthalmos – protrusion of the eyeballs. Graves’ disease is an autoimmune disorder in which antibodies produced by your immune system stimulate your thyroid to produce too much thyroid hormone.

These antibodies mistakenly attack your thyroid and occasionally the tissue behind your eyes (Graves’ opthalmopathy) and the skin, often in your lower legs over the shins (Graves’ dermopathy). Scientists aren’t sure exactly what causes Graves’ disease, although several factors, including a genetic predisposition, are likely involved.

The disease has a genetic component, although not every member of the afflicted families will suffer this condition. It is more common in females than in males.

In Graves’ eye disease, the eyes are painful, red and watery – particularly in sunshine or wind. The eye lids and tissues around the eyes are swollen with fluid. The eyeballs bulge out of their sockets (exophthalmos). Because of eye muscle swelling, the eyes are unable to move normally and there may be blurred or double vision. Some patients have decreased colour vision as well.

Fortunately, the eye changes tend to “burn out” within a period of about 24 months and, in most cases, there is a satisfactory end result even without any treatment. The double vision and the bulginess usually do not disappear completely.

Unfortunately, there is no satisfactory treatment to prevent Graves’ eye disease. Because hyperthyroidism seems to influence the eye disease, it is very important to treat the hyperthyroidism quickly and effectively. In most patients, the eyes tend to get somewhat better when the thyroid abnormality has been treated.

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