Acidity



What is Acidity? Acid reflux is also known as heartburn, acid indigestion, or pyrosis. It happens when some of the acidic stomach contents go back up into the esophagus. Acid reflux creates a burning pain in the lower chest area, often after eating. If acid reflux symptoms happen more than twice a week, it means you have an acid reflux disease, also known as gastroesophageal reflux disease (GERD). What Causes Acid Reflux Disease? One common cause of acid reflux disease is a stomach abnormality called a hiatal hernia. Normally, the diaphragm helps keep acid in our stomach. But if you have a hiatal hernia, acid can move up into your esophagus and cause symptoms of acid reflux disease. These are other common risk factors for acid reflux disease: Eating large meals or lying down right after a meal

Being overweight or obese

Eating a heavy meal and lying on your back or bending over at the waist

Snacking close to bedtime

Eating certain foods, such as citrus, tomato, chocolate, mint, garlic, onions, or spicy or fatty foods

Drinking certain beverages, such as alcohol, carbonated drinks, coffee, or tea

Smoking

Being pregnant

Taking aspirin, ibuprofen, certain muscle relaxers, or blood pressure medications Symptoms

Heartburn

Regurgitation

Early satiety

Bad test in the mouth

Post prandial fullness

Bloating

Bloody or black stools or bloody vomiting

Burping

Dysphagia -- a narrowing of your esophagus, which creates the sensation of food being stuck in your throat

Hiccups that don't stop

Wheezing, dry cough, hoarseness, or chronic sore throat Red Flag

Age > 50 year, with new onset symptoms

Family history of upper-GI malignancy

Unintended weight loss

GI bleeding or iron deficiency anemia

Progressive difficulty in swallowing

Pain while swallowing

Persistent nausea and vomiting

Jaundice Precipitating factors

Dietary indiscretion (high fat, caffeine)

Analgesic abuse

Some prescription medications (ASA, Calcium channel blockers, bisphosphonates)

Excessive alcohol use

Smoking Dyspepsia and H.Pylori

Prevalence of H.Pylori is high in the developing countries. Approximately 80% of Indian population has antibodies against H.Pylori in their sera. Dyspeptic symptoms score are generally significantly higher in patients infected with H.Pylori and it improves with anti-H.Pylori treatment. Complications, if untreated

Upper gastrointestinal bleeding

Stomach and duodenal perforation

Gastric outlet obstruction

Malignancy Recommendations

Patients with dyspepsia who are older than 50 years of age and/or those with alarm features should undergo endoscopic evaluation.

Patients with dyspepsia who are younger than 50 years of age and without alarm features may undergo an initial test-and-treat approach for H. pylori.

Patients who are younger than 50 years of age and are H. pylori negative can be offered an initial endoscopy or a short trial of PPI acid suppression.

Patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy. Can Acid Reflux Disease Be Treated With Diet and Lifestyle Changes?

One of the most effective ways to treat acid reflux disease is to avoid the foods and beverages that trigger symptoms. Here are other steps you can take: Eat smaller meals more frequently throughout the day.

Quit smoking.

Put blocks under the head of your bed to raise it at least 4 inches to 6 inches.

Don't eat at least 2 to 3 hours before lying down.

Try sleeping in a chair for daytime naps.

Don't wear tight clothes or tight belts.

If you're overweight or obese, take steps to lose weight with exercise and diet changes.

Carcinoma Stomach



Gastric malignancies are a major cause of morbidity and mortality in the world. Globally, it is the second commonest site of cancer second only to lung in male accounting for 7.36 million deaths worldwide. China leads with age adjusted incidence rate of 145.4 followed by USA with 43.4 in population based cancer registry worldwide. National Cancer Registry Program by Indian Council of Medical Research (ICMR) states that stomach cancer occupies the leading site (9.1%) in Chennai, fourth leading site (6.4%) in Bangalore, and fifth (5.4%) in Dibrugarh. In Kolkata, it is the ninth leading cause of cancer (3.88% of all sites). Symptoms Significant weight loss

Discomfort or abdominal pain in upper abdomen

Vomiting

Early satiety or feeling of full or bloated after small meal

Difficulty in swallowing

Blood in vomitus

Blood in stool or black colored stool Risk factors

Family history of carcinoma stomach

Long term inflammation of the stomach

H.Pylori infection

Previous stomach surgery

Smoking

Alcohol

Diet high in smoked food, salted food and pickled

Lack of physical activity

obesity Diagnosis

Upper GI Endoscopy- it’s a safe and short day care procedure in which a flexible lighted tube is passed to look in to the stomach and initial part of small intestine

Biopsy- when some suspicious tumor or lesion is found on endoscopy , the tissue can be taken with a forcep for tissue biopsy Staging

to look for how much the cancer has spread in stomach, to surrounding structures and other organs to plan best line of management Endosonography (EUS) - EUS uses the high frequency ultra sound waves to detect the smallest lesion in the wall of stomach or other organs. This is the most accurate modality for detecting early cancer as well as smallest nodes which can be missed by conventional imaging.

CT Scan

Chest X-Ray

Laparoscopy Prevention

Diet high in fresh fruits and vegetables

Avoid smoking, alcohol and tobacco

Avoid eating smoked, salted, pickled and fermented food Treatment

Endoscopic mucosal resection (EMR)- minimal invasive endoscopic treatment of early stomach cancer

Surgery

Chemotherapy

Radiotherapy

Palliation

Inflammatory bowel disease (IBD)



Inflammatory bowel disease can cause symptoms such as abdominal cramps, bloody diarrhea, and fever. Other symptoms of IBD can include weight loss. Inflammatory bowel disease (IBD) is characterized by two major disorders, Ulcerative Colitis (UC) and Crohn’s Disease (CD). Genetics and environmental factors are considered in the patho physiology of these multi factorial disorders. Due to the effect of both genetic and environmental factors on the etiology of IBD, variations exist in the epidemiology an incidence of these disorders worldwide. Ulcerative Colitis

The highest annual incidence rate is 24.3 per 100,000 person-years in Europe compared to 6.3 per 100,000 person-years in Asia and the Middle East.

Types Ulcerative colitis is classified according to the location of inflammation and severity of symptoms: Ulcerative Proctitis - Inflammation is confined to the area closest to the anus (rectum), and rectal bleeding may be the only sign of the disease. This is the mildest form.

- Inflammation is confined to the area closest to the anus (rectum), and rectal bleeding may be the only sign of the disease. This is the mildest form. Proctosigmoiditis - Inflammation involves the rectum and lower end of the colon. Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so.

- Inflammation involves the rectum and lower end of the colon. Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so. Left-sided colitis - Inflammation extends from the rectum up through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss.

- Inflammation extends from the rectum up through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss. Pancolitis - Pancolitis often affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight loss.

- Pancolitis often affects the entire colon and causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight loss. Acute severe ulcerative colitis - Previously called fulminant colitis, this rare form of colitis affects the entire colon and causes severe pain, profuse diarrhea, bleeding, fever and inability to eat. Crohn’s Disease Crohn's disease may involve inflammation in different parts of the digestive tract in different people. The most common areas affected are the last part of the small intestine (ileum) and the colon. Inflammation may be confined to the bowel wall, which can lead to narrowing from inflammation or scarring or both (fibrostenosis), or may tunnel through the bowel wall (fistula). Narrowing may lead to a blockage (obstruction). The highest annual incidence is 20.2% per 100,000 person-years in North America in contrast to 5 person-years in Asia and the Middle East. Both incidence and prevalence of CD and UC is increasing over time, in both Western and developing societies. Symptoms IBD symptoms vary from person to person - and usually over time. IBD is a chronic (long term) disease and if you have IBD you will probably have periods of good health (remission) and then relapses or 'flare-ups' when the symptoms get worse. Abdominal pain and severe cramps when passing stools

Diarrhea (sometimes mixed with blood, especially in ulcerative colitis)

Generalized weakness / fatigue /unwell

Loss of appetite

Weight loss

Anemia

Swollen joints, mouth ulcers and eye problems Complications, if untreated Hemorrhage- profuse bleeding from ulcers

Bowel perforation

Severe Dehydration

Malnutrition

Osteoporosis

Strictures and obstruction (narrowing of the bowels)

Fistulas and perianal disease

Toxic mega-colon (excessive dilation of the colon)

Malignancy

Arthritis

Eye disorders- iritic, uveitis, episcleritis

Inflammation of skin, joints & eyes

Mood disorders- anxiety and depression

Increased risk of blood clots in veins and arteries

Liver disorders- nonalcoholic fatty liver disease Causes The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but don't cause IBD.

One possible cause is an immune system malfunction. When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too. Heredity also seems to play a role in that IBD is more common in people who have family members with the disease. However, most people with IBD don't have this family history. Risk factors Age - Most people who develop IBD are diagnosed before they're 30 years old. But some people don't develop the disease until their 50s or 60s.

Race or ethnicity - Although whites have the highest risk of the disease, it can occur in any race. If you're of Ashkenazi Jewish descent, your risk is even higher.

Family history - You're at higher risk if you have a close relative — such as a parent, sibling or child — with the disease.

Cigarette smoking - Cigarette smoking is the most important controllable risk factor for developing Crohn's disease. However, smoking may provide some protection against ulcerative colitis. The overall health benefits of not smoking make it important to try to quit

Isotretinoin use - may be a risk factor for IBD, but a clear association between IBD and isotretinoin has not been established.

Non-steroidal anti-inflammatory medications - These medications may increase the risk of developing IBD or worsen disease in people who have IBD.

Where you live - If you live in an urban area or in an industrialized country, you're more likely to develop IBD. Therefore, it may be that environmental factors, including a diet high in fat or refined foods, play a role. People living in northern climates also seem to be at greater risk. Recommendations Ileo-colonoscopy is strongly recommended for evaluation of IBD and differentiating ulcerative colitis from crohn’s disease and other diseases causing similar symptoms

Mucosal biopsy specimens are important to diagnose and differentiate between the causes of such symptoms

Colorectal cancer risk is increased in both ulcerative colitis and extensive Crohn’scolitis and surveillance colonoscopy with multiple biopsies should be performed every 1 to 2 years Treatment Treatment for IBD involves a combination of self-care and medical treatment. Dietary and lifestyle changes may be helpful in managing your symptoms. It's important to talk with your doctor about ways to modify your diet while making sure you get the nutrients you need. For instance, depending on your symptoms, the doctor may suggest that you reduce the amount of fiber or dairy products that you consume. Also, small, frequent meals may be better tolerated. In general, there is no need to avoid certain foods unless they cause or worsen your symptoms You may recommend a low-residue diet, a very restricted diet that reduces the amount of fiber and other undigested material that pass through your colon. Doing so can help relieve symptoms of diarrhea and abdominal pain. Be sure you understand how long you should stay on the low-residue diet, because it doesn't provide all the nutrients you need. Your doctor may recommend that you take vitamin supplements. Another important aspect of self-care is to learn how to be stress free, stress may worsen your symptoms. Learning to meditate, creating time for yourself, and regular exercise are all important tools for reducing the amount of stress in your life. Participating in a support group puts you in contact with others who know exactly the effect IBD has on your day-to-day life, because they are going through the same things you are. They can offer support and tips on how to deal with symptoms and the effect they have on you. Medical Treatment The goal of medical treatment is to suppress the abnormal inflammatory response so intestinal tissue has a chance to heal. As it does, the symptoms of diarrhea and abdominal pain should be relieved. Once the symptoms are under control, medical treatment will focus on decreasing the frequency of flare-ups and maintaining remission.

Colon Cancer



Colorectal cancer is a major cause of morbidity and mortality throughout the world. It accounts for over 9% of all cancer incidences. It is the third most common cancer worldwide and the fourth most common cause of death. Worldwide, colorectal cancer represents 9.4% of all incident cancer in men and 10.1% in women. Bowel cancer is the fourth most common cancer in the UK, after breast, lung and prostate cancers. Around 40,700 people are diagnosed with the disease each year. In the United States, colorectal cancer is the third most common cancer diagnosis among men and women. It ranges from more than 40 per 100,000 people in the United States, Australia, New Zealand, and Western Europe to less than 5 per 100,000 in Africa and some parts of Asia Worldwide mortality attributable to colorectal cancer is approximately half that of the incidence. It is estimated that 394,000 deaths from colorectal cancer still occur worldwide annually. Colorectal cancer incidence is influenced by improved diagnostic techniques and screening programs. When bowel cancer is caught at the earliest stage, more than nine in 10 people will survive for more than five years. Colorectal cancer survival is highly dependent upon stage of disease at diagnosis, and typically ranges from a 90% 5-year survival rate for cancers detected at the localized stage; 70% for regional; to 10% for people diagnosed for distant metastatic cancer. Risk factors

Age – the likelihood of diagnosis of colorectal cancer increases after the age of 50

Personal history of adenomatous polyp- tubular and villous adenoma is precursor lesions for development of colon cancer

Personal history of inflammatory bowel disease- the relative risk for increase in colon cancer is 4 – 20 folds

Family history of colorectal cancer or adenomatous polyps- up to 20% of people who develop colorectal cancer have other family members who have been affected by this disease

Inherited genetic risk- Approximately 5 to 10% of colorectal cancers are a consequence of recognized hereditary conditions

Environmental risk factors- include a wide range of often ill-defined cultural, social, and lifestyle factors

Nutritional practices- Diets high in fat (especially animal fat), diet low in fruits and vegetables are a major risk factor for colorectal cancer

Physical activity and obesity- physical inactivity and excess body weight

Cigarette smoking- 12% of colorectal cancer deaths are attributed to smoking

Heavy alcohol consumption- regular consumption of alcohol may be associated with increased risk of developing colorectal cancer Diagnosis

Colonoscopy

FOBT (fecal occult blood test) Screening Guidelines

If you don’t have an increased risk of colorectal cancer because of your personal or family medical history, we recommend screening tests, beginning at age 45

Colonoscopy every 10 years

A yearly test for blood in the stool every five years

If you have an increased risk of colorectal cancer because of your personal or family medical history,

You should have a colonoscopy every 5 years beginning at age 40, or younger if hereditary non-polyposis colorectal cancer (HNPCC) is suspected.

For first-degree, direct relatives of patients with colorectal cancer that has presented before age 50

Screening should begin 10 to 20 years before the age of the diagnosed patient. For example, if your father is diagnosed with colorectal cancer at age 48, then you should begin your own colorectal cancer screening between ages 28 and 38

Constipation





The incidence of constipation is over 10% worldwide and over 15% in India. In Western society constipation probably occurs more than in other cultures – one in six people. It is estimated that as many as one young woman in every 12 suffers with constipation, mainly in their late teens to 20s. Constipation is more frequent in individuals 65 years of age or older. Elderly people report problems with constipation five times more frequently than younger people. In the elderly, up to 50% self-report constipation and up to 74% use laxatives daily. Around 2% of the population suffers recurrent and constant constipation and is more common in women than in men. Causes

Functional problems

Medications- side effect of wide variety of prescribed and over the counter drugs (few examples- codeine, iron tablets)

Pregnancy and after child birth- the gut slows down in the pregnancy due to hormonal changes

Following an operation- the painkillers given after surgery often causes constipation by slowing down the bowel. Food intake may also be erratic or even non-existent. Some major pelvic operations can lead to damage of the pelvic nerves

Eating disorders- patients who fail to eat regularly cannot expect a regular bowel action

Life style and bowel habits- People sometimes feel unable to open their bowels at school or in their workplaces. Over the years, their gastrointestinal tract gradually slows down and they become constipated

Psychological disturbances

Sexual and physical abuse- mostly during childhood

Fear of pain while passing stool

Anatomical problems

Rectocoele- bulging of rectum

Hirschsprung’s disease

Mega colon or mega rectum- large dilated colon

Nerve disease or injury Complications

Rectal prolapsed

Fecal impaction Investigations for diagnosing the cause of constipation

Ileo-colonoscopy- evaluation of cause for symptoms on the bowel lining

Ano rectal physiological testing- this test takes about 15 minutes and looks at the way the muscles and nerves of the rectum and anus are working

Transit studies

Dynamic MRI defaecography

Defaecating proctography Treatment options

Lifestyle modifications

Dietary modifications

Medications

Biofeedback

Surgery- a rare sub set of patient require surgery

Diarrhea





Diarrhea is the passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual Disease Problem

It has been estimated that in any given 24 hr period, 200 million people on earth have gastroenteritis Estimated incidences in industrialized countries are 0.6 episodes per immuno-competent adult per year. Based on ratios between adults and children, estimated incidence in developing countries is 1.0-1.5 episodes per immuno-competent adult per year Diarrheal disease is the second leading cause of death in children under five years old, and is responsible for killing around 760 000 children every year Causes

There are many causes. Diarrhea often is caused by an infection with bacteria, viruses or a parasite. Bacteria cause diarrhea either by invading the intestine or by producing a toxin that makes the intestine secrete more water. When the diarrhea is caused by food contaminated with bacteria or parasites, people often refer to this as food poisoning Other causes of diarrhea include: Irritable bowel syndrome, especially during times of increased stress

Side effects from medications, such as antibiotics and magnesium-containing antacids

Overuse of laxatives

Inflammation of the intestine (ulcerative colitis or Crohn’s disease) Symptoms

People with diarrhea usually have loose, watery stools. Less commonly, people pass frequent, small amounts of loose stool with mucous and blood.

Other symptoms can include: Abdominal pain and cramping

Vomiting

Fever

Chills

Bloody stools

Lack of bowel control

Frequent vomiting and diarrhea can lead to dehydration (abnormally low levels of body water) if too much fluid is lost from the body.

Signs of dehydration include: Dry mouth

Thirst

Dry eyes

Infrequent urination Diagnosis

Detailed history and complete physical examination is necessary to rule out the cause of diarrhea

Stool routine and microscopic examination

Ileo-colonoscopy

Hiatus Hernia



Hiatus hernias affect anywhere from 1 to 20% of the population. Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). People of all ages can get this condition, but it is more common in older people. Types of Hiatus Hernia

1. Sliding Hiatus Hernia

95% of hiatus hernia is "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach.

2. Rolling or Paraesophageal Hiatus Hernia

Only 5% of the hiatus hernia is the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm. Symptoms - In most patients, hiatus hernia cause no symptoms

Heart Burn

Regurgitation

Bleeding and Anemia

Difficulty in Swallowing

Chronic Cough

Wheezing

Pneumonia Who is at risk for development of hiatus hernia?

Old People

Pregnancy

Chronic Cough

Chronic Vomiting

Chronic Constipation

Low Fiber Diet

Obesity

Ascites

Chronic Esophagitis Red flag signs- When to seek urgent medical care?

Blood in vomiting

Black colored stool

Severe abdominal pain

Severe chest pain Diagnosis Upper GI Endoscopy- During this procedure, after you are sedated, an endoscope which is a thin, flexible, lighted tube was passed down your throat to check for any abnormality

High resolution manometry

PH Testing Prevention Treatment of ascites, chronic cough, vomiting and constipation

Healthy diet, avoid western fiber depleted diet

Control weight Treatment options 1. Lifestyle modifications Eating smaller, more frequent meals rather than three large meals a day

Avoiding lying down (including going to bed) for three hours after eating or drinking

Removing any foods or drinks that make your symptoms worse from your diet

Control your weight 2. Medications 3. Surgery Only reserved for emergency situations and in patients who aren’t helped by medication and life style modifications

Jaundice





Jaundice is described as a yellowish discoloration of urine, eyes and skin Signs

Yellowing of the skin, eyes and mucus membrane (the lining of the body's passageways and cavities, such as the mouth and nose)

Pale-colored stools (feces)

Dark-colored urine

Symptoms

Anorexia

Fever

Pain in abdomen

Generalized weakness

Generalized itching

Vomiting

Weight loss Types of Jaundice

1. Pre Hepatic Causes - the disruption occurs before the bilirubin has been transported from the blood to the liver Sickle cell anemia

Hereditary spherocytosis

Thalassemia

G6PD deficiency

Drugs or other toxins

Auto immune disorders 2. Intra Hepatic Causes (Hepato Cellular Jaundice) - the disruption occurs inside the liver Acute or chronic hepatitis

Alcoholic hepatitis

Cirrhosis of liver

Crigler-Najjar syndrome

Gilbert’s syndrome

Liver cancer

Drugs or other toxins

Auto immune disorders 3. Post Hepatic Jaundice (Obstructive Jaundice) - the disruption prevents the bile (and the bilirubin inside it) from draining out of the gallbladder and into the digestive system Common bile duct stones

Cancer (gall bladder cancer, pancreatic cancer, CBD cancer)

Bile duct strictures

Cholangitis

Pancreatitis

Parasitic infections Diagnosis

1. Biochemical Investigations - complete blood counts, liver function tests, tumor markers, electrolytes etc 2. Endosonography (EUS) Endoscopic ultrasound (EUS) combines endoscopy and US to provide remarkably detailed images of the pancreas and biliary tree

It uses higher frequency ultrasonic waves compared to traditional US and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration

Endoscopic ultra sonography overcomes the limitation of evaluation of distal CBD by trans- abdominal sonography. It is very accurate in diagnosing CBD calculi with an overall accuracy of 96% as compared with 63% sensitivity of trans abdominal sonography esp. with small calculi or calculi with non-dilated biliary system

It also picks up small resectable pancreato-biliary mass with high sensitivity (93-100%) 3. CT Abdomen 4. MRCP Complications of jaundice, if not treated

Electrolyte imbalances

Anemia

Bleeding

Infection / Sepsis

Chronic hepatitis

Cancer

Liver failure

Kidney failure

Brain dysfunction

Death Role of Endoscopy

Diagnosis can be made and provides information regarding plan of further management

Biliary stone disease can be cured in the same sitting

Safe, cheap, pain less day care procedure

Anaemia

Anaemia means that you have fewer red blood cells than normal, OR you have less hemoglobin than normal in each red blood cell. In either case, a reduced amount of oxygen is carried around in the bloodstream. It is extremely prevalent in the Indian population and the incidence is said to be 27% of the adult population and 195 of pediatric group. Symptoms

Tiredness, lethargy

Feeling faint, and becoming easily breathless

Headaches, a thumping heart (palpitations)

Altered taste

Ringing in the ears (tinnitus)

You may look pale

Various other symptoms may develop, depending on the underlying cause of the anaemia When to seek urgent medical attention

Vomiting containing blood

Passage of black tarry stool

Recurrent fainting episodes with chronic anemia Causes

Pregnancy or childhood growth spurts are times when you need more iron than usual. The amount of iron that you eat during these times may not be enough.

Heavy menstrual periods. The amount of iron that you eat may not be enough to replace the amount that you lose with the bleeding each month.

Poor absorption of iron may occur with some gut diseases - for example, celiac disease and Crohn's disease.

Bleeding from the gut (intestines). Some conditions of the gut can bleed enough to cause anaemia. You may not be aware of losing blood this way. The bleeding may be slow or intermittent, and you can pass blood out with your stools (feces) without noticing.

Lack of certain vitamins such as folic acid and vitamin B12.

Red blood cell problems such as thalassemia, sickle cell anaemia and other causes of hemolytic anaemia. In these conditions the red cells are fragile and break easily in the bloodstream.

Bone marrow problems and leukemia are uncommon, but can cause anaemia.

Chronic kidney disease can also cause anaemia. Investigations

Complete blood count

Stool for occult blood

Peripheral smear examination

Other Biochemical tests

Upper GI endoscopy

Lower GI endoscopy

Small bowel Enteroscopy

Capsule endoscopy Treatment

Conservative medical management

Tailored treatment according to the underlying cause

Carcinoma Pancreas

Pancreatic cancer is the leading cause of cancer deaths in the world and its incidences are rising in India. Pancreatic cancer is the fifth leading cause of death in United States and approximately 30000 pancreatic cancers are diagnosed per year with an incidence rate of 9 cases per 100000 people. The incidence rate of pancreatic cancer in India is low (0.5 to 2.4 cases per 100000 people). The incidence of pancreatic cancer is higher in urban male populations of western and northern parts of India. Risk factors

Age – 20 times higher risk for individuals older than 50 years

Smoking – tobacco smoking contributes to 20 to 30 % of all pancreatic cancers

Diabetes mellitus – presence of DM, chronic cirrhosis, pancreatitis and fatty diet has a synergistic effect in development of pancreatic cancer

Obesity and lack of physical exercise

Occupational hazards

Genetic predisposition

Miscellaneous Symptoms

Abdominal pain

Weight loss

Dark colored urine

Clay colored stool

Generalized itching

Nausea/Anorexia

Vomiting

Early onset diabetes or uncontrolled diabetes Diagnosis

Biochemical investigations and tumor markers

EUS and guided FNA

CT scan

MRI

FDG- PET Scan Treatment

Surgery

Neoadjuvant and adjuvant chemotherapy

Endoscopic palliation

Supportive medical care

Hepatitis

Hepatitis means inflammation of the liver. There are a number of things that can cause hepatitis. For example, drinking too much alcohol, various drugs and chemicals, and also several different viruses like hepatitis A, B, C, D, E, G. What does the liver do? Storing glycogen (fuel for the body) which is made from sugars. When required, glycogen is broken down into glucose which is released into the bloodstream

Helping to process fats and proteins from digested food

Making proteins that are essential for blood to clot (clotting factors)

Processing many medicines which you may take

Helping to remove or process alcohol, poisons and toxins from the body

Making bile which passes from the liver to the gut down the bile duct. Bile breaks down the fats in food so that they can be absorbed from the bowel Symptoms

Flu-like symptoms. For example, general aches and pains and headaches. (These are the most common symptoms.)

Tiredness, feeling sick, sometimes being sick (vomiting) and diarrhea

An ache over your liver (the upper part of the right side of your tummy (abdomen) below your ribs) Diagnosis

The doctor performs a liver profile along serological testing of various viruses and a battery of blood tests to rule out other related conditions

An ultrasound of the liver is carried out too Prevention

Hepatitis B, C and D are transmitted via sexual contact, blood transfusion, sharing of needles or vertically to the offspring from the mother. Prevention of hepatitis A, E, G

Raw or inadequately cooked shellfish

Raw salads and vegetables that may have been washed in dirty (contaminated) water. (Wash fruits and vegetables in safe water and peel them yourself.)

Other foods that may have been grown close to the ground such as strawberries

Untreated drinking water, including ice cubes made from untreated water. (Remember also to use only treated or bottled water when brushing your teeth.)

Unpasteurized milk, cheese, ice cream and other dairy products

Stones

Stone diseases can be divided in to three categories for better understanding as far as the gastro-intestinal tract is concerned. 1. Gall Bladder Stones

2. Common Bile Duct Stones

3. Pancreatic Stones

1. Gall Bladder Stones

Gall bladder stone disease is increasing dramatically. In Japan, prevalence of gall bladder stone disease has been increased to double in last fifty years. Highest prevalence of gall bladder stone disease was noted among Native American Indians of Arizona, incidence of as high as 73% was noted among females at the age of 30. In US, the prevalence of gall stone disease is ranging from 5.9 to 21.9 %. In India, the prevalence of gall bladder stone disease is up to 6.12 %, with Chandigarh and Delhi having the highest number of gall stone disease. The prevalence for development of gall stone disease is increased progressively to reach a peak in the sixth decade. Symptoms Asymptomatic gall stone disease- patient may not have symptoms as long as 15-20 years. But approximately 20% of them develop symptoms by 15 years

Abdominal colicky pain over right upper abdomen

Nausea

Vomiting

Fever

Jaundice Risk factors

Age – peak in 40-60 years

Gender- females are more prone M:F-1:2

Nationality – North India, Scandinavia, Northern Europe, Chile

Race/Ethnicity- PIMA Indians of south Africa, native American tribes, Alaskans

Family history- high risk in first degree relatives of gall stone patients

Obesity

Rapid weight loss

Multi parity

Diabetes mellitus

Bowel diseases

Total parenteral nutrition

Spinal cord injuries Complications

Pancreatitis

Fistula between gall bladder wall and bowel

Gall bladder perforation

Gall stone ileus- gall bladder stone may pass in to the bowel causing obstruction

Mirizzi syndrome

Emphysematous cholecystitis

Gangrene of gall bladder

Choledocholithiasis- gall bladder stones may pass in to CBD causing jaundice and infection

Porcelain gall bladder

Gall bladder carcinoma Diagnosis

Trans abdominal sonography

Endoscopic ultra sonography- a novel non invasive modality for diagnosis of pancreato-biliary disorders, which is safe, accurate and less time consuming

CT scan

MRCP

HIDA Scan

Biochemical and other investigations Treatment

Medical management- not much role

Open cholecystectomy

Laparoscopic cholecystectomy

EUS guided cholecysto-duodenostomy:- needs further clinical studies and FDA approval 2. Common Bile Duct stones

Bile duct stones are present in approximately 7-12 % of patients with gall bladder stones. Common bile duct stones may be due to slippage of gall bladder stones in to the CBD or they can form de novo. Symptoms

Abdominal colicky pain

Fever

Jaundice

Nausea

Vomiting

Disorientation Risk factors

Obesity

Low fiber, high calorie, high fat diet

Pregnancy

Prolonged fasting

Sudden weight loss

Lack of physical activity Complications

Pancreatitis

Mirizzi syndrome

Cholangitis Diagnosis

Trans abdominal sonography

EUS- a novel non invasive modality for diagnosis of pancreato-biliary disorders, which is safe, accurate and less time consuming

CT Abdomen

MRCP

Biochemical and other investigations Treatment

ERCP- gold standard treatment for management of CBD stone. Minimal invasive, safe and day care procedure in expert’s hand

Laparoscopic CBD exploration

Open CBD exploration

ESWL 3. Pancreatic duct stones

A pancreatic duct stone disease was supposed to be rare disease but the incidence of the disease has been shown to rise recently, especially in western countries. Pancreatic duct stones are found in 20-60% of the patients with chronic pancreatitis. Pancreatic duct stones usually results from chronic inflammation and altered metabolism. Symptoms

Upper abdominal pain- radiating to back, pain increased after having food

Nausea

Vomiting

Oily, fatty stools

Weight loss

Indigestion Risk factors

Alcohol

Smoking

Obesity

Sedentary lifestyle

Genetic

Autoimmune

Unknown Complications

Acute pancreatitis

Chronic pancreatitis- pancreatic ascites, pseudocyst of pancreas

Diabetes

Malignancy Diagnosis

EUS- it helps in mapping of pancreas and plan further line of management. It helps in evaluation of ductal and parenchymal disorders

MRCP

CT Abdomen

Trans abdominal sonography

Biochemical and other investigations Treatment

Medical management

Lifestyle and dietary changes

ERCP- gold standard treatment for pancreatic ductal stones which is safe, pain free, less time consuming, minimal invasive and less morbidity compared to surgery

ESWL

Open surgery

Laparoscopic surgery