Gastroparesis

Gastroparesis is a disease that affects the muscles, or the nerves controlling muscles of the stomach. It results in improper grinding of food and delayed emptying of the stomach. In a normal person, the vagus nerve controls the muscles of the stomach which break down the food and move it further into the intestines by contracting. Any damage to the vagus nerve whether by injury or illness, will result in disruption of this function. The most common disease considered responsible for gastroparesis by nerve damage is diabetes mellitus. The second most common cause is idiopathic; no such reason can be found and it is termed as idiopathic gastroparesis. An example of the disease causing gastroparesis due to damage to stomach muscles is Scleroderma. In some cases, the problem is neither in the muscles not in the nerves; it is simply due to nerve reflex e.g. when there is pancreatitis. Apart from these, an imbalance in the levels of minerals (e.g. calcium, potassium etc) in the blood, and thyroid disease can also be responsible for causing gastroparesis.

Gastroparesis primarily presents with nausea and vomiting which mainly occurs after meals but can also be due to gastric secretions in some severe cases. These symptoms are followed by bloating, abdominal pain, abdominal distention, early satiety (patient feels full on eating small amounts of food), and weight loss. Improper or reduced food intake further leads to nutritional deficiencies.

A diagnosis, as in most diseases, is established through a thorough medical history and physical examinations, blood tests. In this case, there is a need to rule out structural problems or blockage in the GI tract. This is done through various tests including upper gastrointestinal endoscopy, upper GI series, ultrasound, gastric emptying scintipraphy, smart pill (a small electronic device that is swallowed and then moves around the GI tract and records information about the time taken for food to pass through the tract), breath test (radioactive material is ingested and breath samples are taken at regular intervals to calculate the emptying rate of the stomach). A new study known as antro-duodenal motility study has emerged that can measure the pressure generated by the contractions of the stomach and intestinal muscles. It is however still experimental and reserved for selected case. Another experimental study called electrogastrogram that works on same principle as EKG and records the signals that travel through the muscles of the stomach.

Gastroparesis treatment mainly includes diet, medication and procedures to help emptying of the stomach. The diet plan is based on foods that are easily emptied from the stomach; soft, liquid diet. The food should also be low in fiber and should mostly be eaten early during the day. The medications are given to treat the underlying conditions such as diabetes mellitus.

Medication to relieve nausea, vomiting and abdominal pain include promotility drugs (metoclopromide, domperidone, etc), anti-nausea drugs (prochlorperazine, promethazine, etc), medical marijuana (marinol), serotonin antagonists (ondansetron), and anticholinergics (scopolamine).

Drugs for reliving abdominal pain include NSAIDs (ibuprofen, naproxen, etc), tricyclic antidepressants (amitriptyline), nerve blockers (gabapentin), narcotics (tramadol, fentanyl, etc). Some drugs such as cisapride, domperidone, metoclopromide, and erythromycin are used to stimulate the contractions in the muscles of the stomach. As the stomach emptying is affected, liquid medications are preferred over oral as they are more effective in this condition.

A new method called electrical pacing is used to treat severe cases of gastroparesis. A pacemaker for the stomach is placed laproscopically and then generates impulses. Surgery can also be performed to facilitate emptying by creating a larger opening between the stomach and intestines. Sometimes, the entire stomach may be removed. However, surgery should be the last option of treatment.

Patients of gastroparesis suffer from malnutrition and dehydration which can be managed by IV fluids and replenishing of electrolytes. This involves methods such as IV total parenteral nutrition (TPN) and enteral nutrition. Enteral nutrition is preferred over TPN and can be done via naso-jejunal tubes or jejunostomy tubes. Treatment with botulinum toxin may be effective but is currently under study.

Clinical research is being conducted at National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), for new medications or surgical methods that can cure gastroparesis more effectively and safely. More information can be found at cancercarevilla.blogspot.com.

Facts That a Common Man Should Know About Hidradenitis Treatment

Hidradenitis Suppurativa is defined to be a dermatological condition that has a tendency to affect the areas that are containing the sebaceous or sweat glands. The areas most commonly involved are the breasts, axillae, groin, buttocks and thighs. Sometimes, it may also involve the anal region.

Hidradenitis Suppurativa can be easily diagnosed by a dermatologist and Hidradenitis treatment usually focuses on how severe the condition is. There are four main options that can individually or cumulatively applied on the treatment of Hidradenitis Suppurativa: Lifestyle, Pharmacotherapy, Radiotherapy and Surgery.

1.      Lifestyle:

It has been seen that diet plays a major role in the treatment of Hidradenitis Suppurativa.

Foods that are extremely high in refined carbohydrates and fried foods have been seen to play a role in the development of this condition. This explains why this condition is commonly seen amongst overweight and obese patients.

Warm compresses are helpful when applied to the affected area and best results are seen when they are applied with distilled vinegar water. This is commonly known as hydrotherapy. Alternatively, pain reduction can be done by icing the inflamed area once/twice daily.

2.      Pharmacotherapy:

Antibiotics are of particular use in the treatment of Hidradenitis Suppurativa because they aim to reduce inflammation and infection both. The combination therapy of clindamycin and rifampicin has been considered to be the most effective till date. The topical application of clindamycin is also considered to be really useful. This therapy is used for a course of 3 months. Alternative antibiotics that can be considered are tetracyclines.

Vitamin A therapy is used because it promotes the growth of new skin. Similar mechanism of action is seen in Zinc also therefore it is also usually prescribed. Additionally, corticosteroid injections are considered to be extremely useful for the localized diseases because of their superior anti-inflammatory effects. Anti-TNF alpha inhibitors are amongst the recently available drugs which are given in injectable forms and are also efficient in waning off inflammation.

For cleansing the skin, usage of antibiotic soap and chlorhexidine is recommended. Also, turmeric powder can either be used topically or capsules are also shown to be effective. In the hidradenitis treatment principles, it must also be known that a keratolytic agent is also recommended as it targets the lesion site and heals it. Topical resorcinol is an example of keratolytic agent. Nowadays, Anti-androgen therapies in the form of estradiol and cryproterone acetate have proven to be useful. However, randomized controlled trials for these are still underway.

3.      Radiotherapy:

For Hidradenitis treatment, electron beam radiotherapy has been shown to be of promising effect. Commonly being used in Europe, it is still a resilient form of treatment in United States because oncologists resist treating patients with electron beam radiotherapy unless they have a cancerous disease going on.

4.      Surgical treatment:

After all the above mentioned treatments, there are still some unfortunate patients who have Hidradenitis Suppurativa which is resistant to all forms of treatment. In this situation, it is advised for a wide surgical excision of the affected area. Since wounds in this area are unable to heal by secondary intention, usually, skin flap from the patient’s own body part is grafted on the surgically excised area.

Usually, Hidradenitis responds to medical therapy and rarely does any need come for radio/surgical therapy. The main treatment still resides in dietary modification and if a good diet control is achieved, the lesions can themselves resolve away and further lesions can be prevented from formation. Also, preventing the triggering factors (obesity, tight clothing, shaving affected area, oral contraceptives and hot/humid climates) can themselves bring a lot of change to this disturbing dermatological condition. 

Facts about Testicular Cancer and Its Treatment Options

According to the National Cancer Institute, the estimated new cases of testicular cancer were 8,590 and the deaths were 360 in 2012. This cancer is considered to be the most common cancer in the males of age groups of 20-39 years. The good thing about this cancer is that there is almost 90% cure rate for this cancer.

Testicular cancer is commonly seen in patients who belong from the Caucasian region and is rarest amongst those in Africa. It is also rarely found in Asia and there have been highest rates of occurrence of cancer in New Zealand, Germany and Scandinavia. There are many risk factors for the development of this cancer, the most common being un-descended testis (also known as cryptorchidism), mumps, inguinal hernias and sometimes, Klinefelters Syndrome.

Testicular cancers have many subtypes. The most common of these cancers are Germ Cell Tumors which account for 95% of all the tumors. The other common subtypes are Sex-cord Gonadal Stromal Tumors. These are derived from the Leydig Cells or Sertoli Cells in testis.  

Testicular cancer often presents with the cardinal symptom of feeling a “lump” in the testis. Additionally, it may also present with symptoms of a dull or sharp pain in the lower abdomen, feeling of something sagging or heavy in the scrotum and sometimes of lower back pain. In rare cases, it may metastasize to other organs (most commonly the lung) where it may present symptoms such as shortness of breath and cough sometimes with bloody sputum. While discussing the symptoms of cancer, we must also know that there are some testicular cancers which secrete the hormone β- hCG because of which gynecomastia (enlargement of breast tissue) in males can be seen.  

Diagnosis of this cancer is extremely vital as wrong diagnosis may miss it altogether. If a young adult or someone in the late adolescent group comes with a unilateral mass in testis then a suspicion of testicular cancer should be kept in mind. An ultrasound is necessary to determine exact location, size and it is highly sensitive in determining the characteristics of the lump such as cystic/solid and whether its borders are sharply defined or not. Additionally, serial CT scans are important in determining if the cancer has spread to any other parts of the body.

Diagnosis of testicular cancer also involves biopsy of the testicular mass and the estimation of blood levels of some hormones namely alpha-feto protein (AFP), β- hCG and LDH. Presence of any of these determines the specific sub-type of testicular cancer.

Once the testicular cancer is diagnosed and staged, the next step is of treatment. There are three basic types of treatments that are instituted for the removal of testicular cancer:

1.      Surgery: Usually performed by uro-surgeons, the surgery is involved to remove the entire testicle. This procedure is known as orchiectomy. It must be known that only one testicle is required for fertility so removing one testis does not affect the fertility of the individual. In Stage I cancer where there is involvement of some retro-peritoneal lymph nodes also, surgery is performed to remove these nodes.

2.      Chemotherapy and 3. Radiation Therapy: Are instituted where the cancer has overcome the boundaries of the scrotum and has spread to many other regions of the body. In non-seminomas, BEP (Bleomycin-Etoposide-Cisplatin) Therapy is used. In the case of seminomas, carboplatins are used.

Success of Modern Medicine: This is what is defined as the prognosis of testicular cancer by the New England Journal of Medicine. Regardless of whatever stage the patient is suffering from of testicular cancer, the average success rate is still around 90%.