Month: August 2016

Appendicitis

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Appendicitis is acute inflammation of vermiform appendix. So first you should know about Appendix.
Appendix is actually a vestigial part of intestinal tract, it looks like a worm therefore named as vermiform appendix. It is a hollow tube like structure which is closed at one end and connected to cecum at another end. Cecum is a pouch like beginning of large intestine.
Appendix is located at the right lower side of the abdomen, it is around 3-4 inches long and roughly a quarter of an inch in diameter. Though it is a vestigial remnant of large cecum but still its functions are not clear. Presence of lymphoid tissue supports the role in immune system whereas another function is the collection of beneficial bacteria which is helpful in illness. The inner lining of the appendix produces a small amount of mucus that flows through the open central core of the appendix and into the cecum.

Appendicitis
If anything blocks the opening of appendix or prevents it from expelling its contents into the cecum may result in appendicitis means inflammation of appendix, which is very painful and if spreads it may be dangerous. Appendicitis may be Acute or chronic and one of the most common cause of abdominal pain .It is a clinical emergency. Most common cause of obstruction is fecolith (hardened pieces of fecal material), obstruction leads to multiplication of bacteria and worsening inflammation. Because of blockage of appendix fluid and mucus collection occurs inside appendix leads to edema, swelling and distention of the organ, and when it bursts spilling of all its content in the abdominal cavity and the surrounding organs will lead peritonitis. Therefore appendicitis is an emergency and surgical removal of the appendix is the definitive treatment.

Causes of appendicitis
An obstruction, or blockage, of the appendiceal lumen causes appendicitis. Mucus backs up in the appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a result, the appendix swells and becomes infected. Sources of blockage include
 Stool, parasites, or growths that clog the appendiceal lumen
 Enlarged lymph tissue in the wall of the appendix, caused by infection in the GI tract or elsewhere in the body
 Inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis, long-lasting disorders that cause irritation and ulcers in the GI tract
 Trauma to the abdomen
An inflamed appendix will likely burst if not removed.

Symptoms
1. Pain- Initially pain starts around the navel or all over the abdomen and after few hours it is localized to right lower side of the abdomen. The pain may be very severe that discomforts patient to move in any position or at rest. Patients usually lie down, flex their hips, and draw their knees up to reduce movements and to avoid worsening their pain
2. Fever usually low grade
3. Nausea and vomiting
4. Constipation or diarrhea
5. Anorexia/loss of appetite
6. Inability to pass gas
7. The feeling that having a bowel movement will relieve discomfort

How to Diagnose?
1. Clinical symptoms with medical and surgical history.
2. Physical examination with detailed abdominal exam- Health care provider will examine abdomen for specific signs of appendicitis ( Rovsing’s sign, Psoas sign, Obturator sign, Guarding and Rebound tenderness)
Women of childbearing age may be asked to undergo a pelvic exam to rule out gynecological conditions, which sometimes cause abdominal pain similar to appendicitis.
3. Laboratory test -Some tests which are used to confirm appendicitis
Blood test will show high WBCs (white blood cell count) usually more than 10,500 cells/        µL,   which is a sign of infection.
Check the level of Serum electrolytes- sodium(Na), potassium(K), Magnesium(Mg),              Chloride and Calcium(Ca).
Urine analysis to rule out pregnancy , UTI and kidney stones.
4. Imaging test-
Abdominal X- ray to detect obstruction.
Abdominal ultrasound to identify enlarged or inflamed appendix, abscess and in females to rule out ovarian torsion or other related disorder.
CT scan – Imaging test to identify inflamed or enlarged appendix, abscess, and other abdominal disorders. Women of childbearing age should have a pregnancy test before undergoing a CT scan. The radiation used in CT scans can be harmful to a developing fetus.
MRI- MRI used to diagnose appendicitis and other sources of abdominal pain is a safe, reliable alternative to a computerized tomography (CT) scan.

Treatment
Surgical removal of appendix is the definitive treatment of appendicitis. Therefore if health care provider finds classic symptoms and signs of appendicitis so without performing imaging test surgeon can perform laparotomy for removal of appendix and complications can be greatly reduced. Appendectomy is preceded by IV antibiotics and iv fluids.
Surgical removal of appendix is called appendectomy which can be either through laparotomy or laparoscopy.
Laparotomy– Laparotomy removes the appendix through a single incision in the lower right area of the abdomen.
Laparoscopy– Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparoscope. But intraabdominal adhesions are contraindication of laparoscopic surgery. Advantage of this is fast recovery and very low chances of post operative infection. Surgeons recommend limiting physical activity for the first 10 to 14 days after a laparotomy and for the first 3 to 5 days after laparoscopic surgery.

Abscess– Sometimes an abscess forms around a burst appendix called an appendiceal abscess. A surgeon may drain the pus from the abscess during surgery or, more commonly, before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgeons operate to remove what remains of the burst appendix.

Fact about appendicitis
Appendicitis is a medical emergency that requires immediate care. People who think they have appendicitis should see a health care provider or go to the emergency room right away. Swift diagnosis and treatment can reduce the chances the appendix will burst and improve recovery time.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source – http://www.niddk.nih.gov The National Institute of Diabetes and Digestive and Kidney Diseases, Encyclopedia Britannica, Merckmanuals.com

UTI (Urinary Tract Infection)

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What is UTI?
Urinary tract infection is UTI, so first you should know about urinary tract. Urinary tract consist of two kidneys, two ureters, one bladder and one urethra. Kidney plays a very important role in excretion of metabolic waste products and formation of urine. The ureters drain urine from kidney and deliver it to the bladder. Function of bladder is to store urine and then release during micturition. The urethra is the tube through which urine passes from the bladder to the exterior of the body. The female urethra is around 2 inches long and ends inferior to the clitoris and superior to the vaginal opening. In males, the urethra is around 8 to 10 inches long and ends at the tip of the penis.
Infection in the urinary tract caused by microorganisms and most common bacteria is E.coli derived from gastrointestinal tract. UTI is the term commonly used to describe urethritis and cystitis, infection in the urethra called as urethritis and infection in the bladder is called as cystitis. But infection can be in any part of the urinary tract from the kidney to urethra. Microorganisms or bacteria can travel from urethra to bladder, bladder to ureter, and ureter to the kidney which may result in pyelonephritis (infection in the kidney).
Urinary tract is divided in to
Upper urinary tract consist of kidney and ureter and
Lower urinary tract consist of bladder and urethra.

Urinary-System
Causes of UTI
E.coli is the most common microorganism to infect urethra but other microbes proteus, pseudomonas, streptococci, staphylococci and klebsiella are also common. Chlamydia and Mycoplasma can infect the urethra and reproductive system but not the bladder. Chlamydia and Mycoplasma infections may be sexually transmitted and require treatment of sexual partners.
UTI is more common in women because in women, the ascent of organisms into the bladder is easier than in men; the urethra is shorter and the absence of bactericidal prostatic secretions may be relevant.
Sexual intercourse may cause minor urethral trauma and transfer bacteria from the perineum into the bladder.
Risk Factors of UTI
1. Poor Hygiene
2. Using dirty toilets
3. Multiple sexual partner or new sexual partner
4. Using a diaphragm for birth control, because it may slow urinary flow and allow bacteria to multiply.
5. Condom use may also cause UTI because of minor vaginal trauma during intercourse.
6. Tampons and spermicidal jelly may cause irritation of vaginal and surrounding skin which can result in UTI.
7. Pregnancy
8. Menopause (atrophic urethritis and atrophic vaginitis)
9. Nerve damage around bladder or in spinal cord injury patient can not completely empty bladder which can allow bacteria to grow.
10. Using catheters in bedridden patients.
11. Diabetes
12. Bowel incontinence
13. Any instrumentation in the bladder or urethra during surgery.
14. Kidney stones
15. Enlarged prostate
16. Inappropriate use of antibiotics (interrupt natural flora of gastrointestinal tract and urinary tract).

Symptoms of UTI
Symptoms of UTI depends upon age, gender, other associated disorders, presence of catheter and the site of infection.
1. Abrupt onset of frequency of micturition and urgency.
2. Dysuria (pain in the urethra or burning sensation during micturition).
3. Pain in lower abdomen during and after urination.
4. Cloudy urine with an unpleasant odor.
5. Sometimes blood in urine (hematuria which may be microscopic or visible).
6. Fever (when infection reached to kidney, usually in catheterized patients but it can be the first symptom in men).
7. Nausea and vomiting if infection is severe.
Acute Pyelonephritis is a condition when infection spreads to the kidney, recognized by fever with chills, rigors, nausea, vomiting, loin or back pain, hypotension, guarding or rigidity may be an indication of hospitalization.
Diagnosis-
1. Clinical symptoms with medical and surgical history.
2. Investigations/lab tests-

      Urine Dipsticks
Urine microscopy and cytometry
Urine Culture to know microorganism

For these tests patient is asked to collect clean catch urine by washing and wiping genital area and midstream urine sample in a sterile container, so that bacteria around the genital area cannot come in to the urine sample and will prevent the confusion of test results.
       Blood test for complete blood count, urea and electrolytes in infants, children and patients with fever or any complicated infection.
       Blood culture
Imaging tests-
USG (ultrasonography)– Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure.
CT scan – CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images.
MRI – MRI machines use radio waves and magnets to produce detailed pictures of the body’s internal organs and soft tissues without using x rays.
Radionuclide scan– A radionuclide scan is an imaging technique that relies on the detection of small amounts of radiation after injection of radioactive chemicals. Special cameras and computers are used to create images of the radioactive chemicals as they pass through the kidneys.
Urodynamics – Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine. Most of these tests are performed in the office of an urologist—a doctor who specializes in urinary problems—by a urologist, physician assistant, or nurse practitioner. Some procedures may require light sedation to keep a person calm.
Cystoscopy – looking inside the bladder and urethra with a camera lens inserted via the urethra through a long thin tube.
Pelvic examination in women and rectal examination in men.
Investigations to diagnose UTI depends upon age, gender clinical symptoms and severity of infection thus use selectively.
Treatment of UTI
Because UTI caused by microorganisms mostly bacteria so antibiotics are recommended to treat the UTI, after getting the results of urine culture which usually takes 48-72 hours. For lower UTI usually 3 days course of antibiotics are recommended. Trimethoprim is the first choice of treatment if bacteria is trimethoprim sensitive, but for trimethoprim resistant bacteria nitrofurantoin or quinolones are effective.
In severe infections treatment may continue for 7-14 days, depending upon patient’s condition doctor decides for intravenous or oral treatment.
Penicillins and cephalosporins are safe to use in pregnancy but trimethoprim, sulphonamides, quinolones and tetracyclines should be avoided.
Fluid intake of 2-3 liters and urinating frequently is usually recommended to flush out the toxins of kidney.
Prevention of UTI
1. Good personal hygiene
2. Drink plenty of fluids around 3 liters per day
3. Urinate frequently if you feel to empty the bladder, do not hold for long time
4. Cranberry juice helps to prevent infection.
5. Urinate before and after sexual intercourse.
6. Wipe from front to back after toilet, in that way bacteria will not come from anal region to urethral region.
7. During menstruation change pads frequently and tampons use should be avoided.
8. Use non-spermicidal lubricated condoms, because spermicidal jelly is skin irritant which cause bacteria to grow and results in UTI.
9. Use cotton and loose fitting underwear and clothes to keep area around urethra dry.
10. Avoid irritant feminine products like deodorant sprays, powders or douches which irritate urethra.
11. Quit smoking
12. Choose healthy diet rich in fibers, protein.
13. Avoid caffeine, nicotine, carbonated soft drinks, spicy food and alcohol.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Image curtsey –shutterstock.com
Content source– Davidson’s Principles and Practice of Medicine (22nd edition), The National Institute of Diabetes and Digestive and Kidney Diseases niddk.nih.gov

Kidney Stones

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Kidney plays an important role in excretion of many metabolic breakdown products, including ammonia, urea and creatinine from protein and uric acid from nucleic acids, drugs and toxins. Kidney also plays an important role in regulation of fluid and electrolyte balance. Kidney regulates acid base homeostasis, calcium and phosphate homeostasis, Vitamin D metabolism and production of red blood cells. It has very important role in regulation of blood pressure also.

Renal stone or kidney stone disease is common which can affect all age group and in individuals living anywhere in the world.
Kidney stone consists of aggregates of crystals, which may be either calcium or phosphate or proteins. Kidney stones form in urine and can travel from kidney to bladder through the urinary tract, so It may be anywhere from the kidney to the ureter. Size of calculi or stone may vary greatly from a minute sand particle to large round stone usually in the bladder. Usually crystal deposition occurs in concentrated urine therefore dehydration is a major risk factor for stone formation. Very small stones usually pass through urine without any problem but larger stone causes obstruction and causes pain, infection and bleeding.

The common sites of obstruction from a stone in the upper urinary tract are located at the:
• Junction where the kidney meets the upper ureter,
• Mid portion of the ureter, or
• Lower ureter at its entry into the bladder

Based on the location of stone term used, for example; stone in the kidney called as nephrolithiasis, stone in the urinary tract termed as urolithiasis, stone in the ureter termed as ureterolithiasis.

Types of stones

Most common type of kidney stone is calcium oxalate around 60% and least common type of kidney stone is cysteine which is around 1%.

Calcium oxalate 60%
Calcium phosphate 15%
Magnesium ammonium phosphate (struvite) 15%
Uric acid 10%
Cysteine and others 1%

Calcium stones- when calcium combines with another mineral like oxalate or phosphate then Ca-oxalate, or Ca-phosphate insoluble crystals form. These can be easily seen on plain X –ray. Usually, no specific cause is found on why these stones develop, however they can occur in certain medical conditions such as hyperparathyroidism, certain types of weight reduction surgery, and in several types of kidney disorders.
Magnesium ammonium phosphate (struvite) – Most important cause is infection of urinary tract (by urease producing organisms), which causes rapid stone growth.
Uric acid stones– Uric acid is a product of purine metabolism. Uric acid is 100 times more soluble at a pH > 6 compared to a pH <5.5. Other than dehydration, the most common risk factor for uric acid stone is persistently acidic urine, more commonly due to excessive high protein diet, obesity or gout. These stones cannot be seen on plain X- ray.
Cysteine stones– these are rare and due to an inherited defect in amino acid transport within the kidney. An excess of cysteine crystals are found in the urine of affected patients which clump together to form stones. Patients who are affected tend to be young and develop recurrent kidney stones throughout life. Long term treatment involves close surveillance, education, dietary changes, fluids, and sometimes medications to prevent the stones from recurring.

Predisposing Factors for the Kidney Stones
1. Environmental causes– high ambient temperature and decrease fluid intake leads to dehydration which is a very important risk factor for the kidney stones.
2. Dietary causes – Diet high in protein, high in sodium and low calcium promotes the renal stone.
3. Medical causes – Hypercalcemia due to any cause, hyperparathyroidism, gout, renal tubular acidosis and urinary tract infection are major risk factors for the kidney stones.
4. Surgical causes– surgeries like ileal resection or gastrointestinal tract surgery, weight loss surgery can also promote the kidney stones.
5. Hereditary cause– If someone in the family has history of renal stone then there are more chances to develop renal stone in the individual. Some diseases like familial hypercalciuria, cysteinuria, medullary sponge kidney, primary hyperoxaluria are other conditions which can cause the kidney stones.
6. Medicines- People taking certain medications like diuretics, calcium based antacids, Indinavir (protease inhibitor used for treatment of HIV), topiramate (antiseizure) are also at increased risk of developing the kidney stones.

Symptoms
Symptoms are greatly vary. Sometimes patient is asymptomatic but most commonly it presents with acute severe pain at the flank (loin) which radiates to anterior abdominal wall or to the groin, it may radiate to testes or labium and anterior/lateral region of thigh. Pain intensity increases in few minutes, patient becomes restless and tries to change position, pain may be associated with vomiting, pallor and sweating. Sometimes hematuria (blood in urine), dysuria (difficulty in passing the urine), or fever with chills (if there is infection in urinary tract or in kidney) may occur due to the kidney stones. The intense pain usually subsides within 2-3 hours but constant or intermittent dull pain in the loin or back may persist for hours to days.

How to Diagnose?
1. Symptoms- Typical excruciating pain on the site of stone or loin and radiates to anterior abdominal wall or groin region, and other symptoms described above.
2. Physical exam, medical history, surgical history, family history and diet.
3. Urine analysis to know any infection, blood in urine, protein, glucose, amino acids, urea, creatinine, sodium, calcium, oxalate and uric acid.
4. Blood test will show any biochemical problem which can cause the kidney stone.
5. Imaging technique –about 90% stones contain calcium can be seen on abdominal X ray but CT scan of Abdomen(KUB-kidney ureter bladder) is the best way to diagnose the kidney stone.
6. Sometimes your doctor can ask for IVP to know the proper flow and excretion from the kidney or USG to know the stones within the kidney and if there is any obstruction in urine flow.

What is the treatment?
Treatment of the kidney stones depends on the size and location of stone, But immediate treatment is analgesic with antiemetic because renal colic is unbearably painful and demands strong analgesic.
If stone is less than 4mm diameter it may pass spontaneously through the urinary tract with increase intake of fluids. In certain situations, a tablet called tamsulosin may be beneficial in helping pass a kidney stone which is obstructing the ureter.
If an underlying infection is suspected (fever or chills), urgent medical treatment should be sought immediately with antibiotic coverage. Patients with kidney stones are at high risk for developing infection so antibiotic coverage is also important.
Stones bigger than 6 mm in diameter require endoscopic surgical intervention. Depending upon clinical presentation and site of obstruction your doctor may choose any of the following surgical procedure.
ESWL(Extracorporeal shock wave lithotripsy)– This procedure is performed by the urologist, in which shock waves generated outside the body are focused on the stone, breaking it into small pieces that can pass easily down the ureter.
PCNL (percutaneous nephrolithotomy) – This procedure is performed by urologist, by using nephroscope through small incision in the patient’s back to locate and remove the stone.
Occasionally, a temporary hollow tube called a stent will be required to assist in keeping the urinary tract unobstructed either before or after definitive stone surgery has been carried out.

Preventive measures-
Prevention is always better than cure.
1. Fluid intake- At least 3 liters of fluid intake is very important to prevent kidney stones formation. Even more oral fluids need to be consumed on hotter days due to insensible losses from perspiration (sweating). A good measure of success is the color of the urine should be clear or a very pale yellow.
2. Low salt intake- decrease sodium intake in the diet or salt restriction. The more sodium you take in and excrete, the more calcium you waste in the urine. Excess calcium in the urine can lead to new stone formation. Try to reduce dietary sources of sodium, including fast foods, packaged or canned foods, and salty snacks. Daily sodium intake should be less than 2000mg per day (around one tea-spoon of salt per day).
3. Low animal protein intake- Protein intake should be in moderate amount not very high.
4. Calcium intake- Maintain good calcium intake (calcium forms an insoluble salt with dietary oxalate, lowering oxalate absorption and excretion). The recommended daily requirement of calcium is 1000 mg, and two-thirds is consumed in dairy containing products. You are encouraged to consume two servings of dairy (but no more than two) or other calcium-rich food per day to maintain normal bone stores of calcium.
5. Oxalate- Avoid foods that are rich in oxalate (spinach, rhubarb)
6. Medicines to prevent stone formation- Diuretics, Allopurinol, Potassium citrate, Penicillamine. Avoid Vitamin D and Vitamin C supplementation.
7. Weight loss- Obesity is a risk factor for kidney stone, so maintain healthy lifestyle and weight loss can prevent kidney stone formation.

Few natural Tips to prevent kidney stones-
 Drink plenty of fluids.
Apple- an apple a day keeps the doctor away. Apple has a diuretic property, which helps to prevent kidney stone.
Pomegranate –Freshly squeezed pomegranate juice helps to prevent stone formation, it has astringent property too.
Celery- celery has high fiber content and natural diuretic so it prevents kidney stone formation.
Basil- Basil is a natural kidney toner, drinking basil tea every day or basil juice with honey is very good remedy for kidney stones.
Kidney beans- Kidney beans are not only very high in fiber, they’re also a great source of non-animal protein, B vitamins, and minerals that improve urinary tracts and kidney health.

 

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

 

Content Source- Davidson’s Principles and Practice of Medicine (22ndedition) , stoneclinic.com.au