Constipation

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Passing stool is a very important part of our life and daily routine, if someone doesn’t pass stool in their routine they always feel discomfort and disturb their routine and mind too.
Constipation means hardening of stool and because of hardening of stool there is difficulty in emptying of bowel usually associated with painful defecation. Constipation is a condition of the digestive system where an individual has hard feces that are difficult to expel. So constipation is a symptom not a disease. Constipation may be acute (recent onset) or chronic(long duration).

Symptoms
Patient may have:
 Few bowel movements
 Trouble having a bowel movement (straining to go)/painful defecation
 Hard or small stools
 A sense of incomplete emptying.
Belly bloating/nauseous
Abdominal cramps
 Losing appetite
Pathology behind Constipation
Slower digestion of food will lead to slower movement through digestive tract and will lead to increase water absorption from the food which causes hardening of stool.

Causes of constipation

1. Decreased water intake
A healthy adult needs to drink at least 2-3 liters of water a day, but decreased intake of water will lead to decreased food digestion process and less hydrated body will make the feces hard, so we should keep hydrated in order to have good digestion and normal feces formation.
2. Physical inactivity
Physical activity keeps metabolism high, so less physical activity will slower metabolic rate and physical inactivity will lead to very slow metabolism.
Physical inactivity also causes constipation, because during physical activity our body muscles including abdominal muscles contract and relaxes which causes intestinal stimulant for contraction and relaxation.
People with sedentary lifestyle, older people, and bed ridden patients usually suffer from constipation.
3. Decreased intake of fibers
Fibers help in digestion and they promote bowel movements, low fiber diet will lead to constipation. It is very important to consume fiber rich diet like salads, fruits, multigrain flour should be part of our diet.
4. Medicines
Some medicines that doctors prescribe to treat other health problems can cause constipation. Medicines that can cause constipation include
Antacids—used to neutralize stomach acid—that contain aluminum and calcium
Anticholinergics—used to treat muscle spasms in the intestines
Anticonvulsants-phenytoin (Dilantin) and carbamazepine (Tegretol) iron supplements—used to decrease abnormal electrical activity in the brain to prevent seizures
Antispasmodics—used to reduce muscle spasms in the intestines
Calcium channel blockers diltiazem (Cardizem) and nifedipine (Procardia)—used to treat high blood pressure and heart disease
Diuretics—used to help the kidneys remove fluid from the blood
Iron supplements—used to build up higher iron levels in the blood
Medicines used to treat Parkinson’s disease
Narcotics—used to treat severe pain
Antidepressants (amitriptyline and Imipramine)
5. Life change from daily routine;
Sometimes because of travel , or any change from your daily routine habits eg; irregular meal time or sleep time, during pregnancy and change in food habits may also cause constipation.
6. Ignoring the urge to have a bowel movements
If individuals ignore the urge to have a bowel movement, the urge can gradually go away until the individual no longer feels the need to go. The longer it is delayed, the drier and harder the stool will become. In kids this is the most common cause of constipation.
7. Overuse of laxative
Some people believe a person should go to the toilet at least once a day – this is not true. However, to make sure this happens, some people self-medicate with laxatives. Using them regularly allows the body to get used to their action and gradually the dose needs to increase to get the same effect. Laxatives can be habit-forming. When a person becomes dependent on them, there is a significant risk of constipation when they are stopped.
8. Certain health problems
Diseases that tend to slow down the movement of feces through the colon, rectum, or anus can cause constipation eg Thyroid disorders (hypothyroidism), Diabetes, some neurological disorders, gastrointestinal disorders like diverticulitis or inflammatory bowel diseases and in certain cancers.
9.Aging
As a person gets older, the metabolism slows down, resulting in less intestinal activity. The muscles in the digestive tract do not work as well as they used to.

Diagnosis of Constipation
Diagnosis of constipation in patient made by full medical, surgical history, family history, complete dietary history, physical examination and by performing some diagnostic tests if need. For example, if defecation is painful, the doctor knows to look for anal problems such as a narrowed anal sphincter or an anal fissure. If small stools are the problem, eating foods low in fiber may be the cause. If the patient is experiencing significant straining, then pelvic floor dysfunction is likely. Depending upon the medical history and symptoms doctor may order for different tests

Blood tests – for thyroid hormones or calcium, or if blood loss from feces then CBC.
Abdominal X ray
Large amounts of material in the colon usually can be visualized on simple X-ray films of the abdomen, and the more severe the constipation, the more visualized on X-ray.
Barium enema
A barium enema (lower gastrointestinal [GI] series) is an X-ray study in which liquid barium is inserted through the anus to fill the rectum and colon. The barium outlines the colon on the X-rays and defines the normal or abnormal anatomy of the bowel and rectum. Tumors and narrowing (strictures) are among the abnormalities that can be detected with this test.
Flexible sigmoidoscopy or colonoscopy.
Anorectal Studies
Anal Manometry– for this test, a health care professional puts a thin tube that has pressure sensors and a balloon on its tip into your anus. Once the balloon reaches your rectum and the pressure sensors are in your anus, the health care professional slowly pulls the tube out to measure muscle tone and contractions. The test takes about 30 minutes.
Balloon expulsion tests consist of a health care professional filling a balloon with different amounts of water after he or she places it into your rectum. The health care professional will give you a stopwatch and instructions to go to the restroom and measure the amount of time it takes you to push the balloon out. If you can’t push out a balloon filled with less than 150 milliliters of water, or it takes longer than 1 minute to push the balloon out, you may have a problem pushing out stool.
Defecography -emptying of the rectum can be tested in the laboratory or with special x-rays.
Sometimes depending upon the condition and other results doctor may order for CT scan or MRI too.

Treatment
In the majority of cases, constipation resolves itself without any treatment or risk to health.
The goal of treatment in constipation should not to have bowel movement every day, but one every two to three days without difficulty (without straining).
Treatment for constipation depends on
• The cause of constipation
• how bad your constipation is
• how long you’ve been constipated means it is acute or chronic
Treatment of constipation should be start with natural remedies
1. Change of dietary habits which include eating more fibers, fruits and vegetables.
2. Intake of water should be increased. Try warm liquids, especially in the morning.
3. Prune juice, act as natural laxative.
4. Lifestyle changes and increasing physical activity. Exercising every day may help prevent and relieve constipation.
5. Flax seed oil as a natural lubricant and laxative.
6. Use of Probiotics/yogurt/buttermilk.
7. Don’t ignore the urge to have a bowel movement.
OTC Laxative
Use of laxative should be as a last resort.
Stimulants: These make the muscles in the intestines contract rhythmically. These include Correctol, Dulcolax, and Senokot.
Lubricants: These help the stool move down the colon more easily. These include mineral oil and Fleet.
Stool softeners: These moisten the stool. Stool softeners include Colace and Surfak.
Fiber supplements: These are perhaps the safest laxatives. They are also called bulk laxatives. They include FiberCon, Metamucil, Konsyl, Serutan, and Citrucel and should be taken with plenty of water.
Osmotics: These facilitate the movement of fluids through the colon. These include Cephulac, Sorbitol, and Miralax.
Saline laxatives: These draw water into the colon.
Chloride channel activators: These require a prescription and include lubiprostone (Amitiza).
5-HT-4 agonists: They increase the secretion of fluid in the intestines and speed up the rate at which food passes through the colon. They include Prucalopride.
If the constipation does not respond to any treatment, as a last resort, surgery to remove part of the colon may be undertaken. In the procedure, the segment of the anal sphincter or rectum that causes the constipation is removed.

Complications
Constipation on its own can be uncomfortable but not life-threatening. However, severe constipation can develop into more serious conditions, including:
1. rectal bleeding after continually straining to pass stools
2. anal fissure, or a small tear around the anus
3. hemorrhoids, or swollen, inflamed blood vessels of veins in the rectum
4. fecal impaction, in which dried stools collect in the anus and rectum, leading to an obstruction in the path stool would take to leave the body
5. Dealing with constipation before it becomes one of these conditions can prevent further discomfort.

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 –https://www.medicalnewstoday.com/articles/150322.php,  https://www.niddk.nih.gov/health-information/digestive-diseases/constipation, https://www.webmd.com/digestive-disorders/digestive-diseases-constipation#1

Important facts about Nutrition

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Nutrition is the most important key related to the health of an individual. Obtaining adequate nutrition is the fundamental requirement of every individual for survival. Recent decade’s people started talking about nutrition and awareness is increasing because overnutrition and undernutrition both causes diseases. Overnutrition gives rise to obesity, cardiovascular diseases, diabetes, cancer and so many diseases.
So here I want to tell you some important facts about nutrition. Quality and quantity both are very important to know about a healthy diet.

Nutrients in the diet can be divided in to two parts:
A. Macronutrients (carbohydrate, protein, and fat)
B. Micronutrients (Vitamins and minerals)

The three macronutrients all have their own specific roles and functions in the body and supply us with calories or energy. For this reason, the body requires these nutrients in relatively large amounts to grow, develop, repair and feel good.
Micronutrients do not contribute to energy balance but need in small amounts because they are not synthesized in our body and help to maintain energy balance, metabolism, cellular, functions, physical and mental health.

Energy balance
With rule of thermodynamics energy intake should be equal to energy output or energy expenditure. Energy intake is regulated by macronutrient content of food. Carbohydrate, fat and protein provide fuel for oxidation in mitochondria to generate energy (ATPs).
In general energy provided by each component differs.
1 g carbohydrates = 4 kcal
1 g of protein = 4 kcal
1 g fat = 9 kcal
Regulation of energy balance is very important for healthy life. Energy intake in the form of food and energy expenditure at various forms first in the form of food metabolism which is called dietary induced thermogenesis (energy required for digestion of food), BMR basal metabolic rate energy expenditure required to maintain metabolic functions in tissues and hence sustain life. Metabolic energy is also required for thermal regulation, and expenditure is higher in cold or hot environments. Another and most important factor is muscular activity which is usually different in all individuals depending upon their occupation and lifestyle.
Regulation of energy balance is coordinated in the hypothalamus, which receives afferent signals that indicate nutritional status in the short term and the long term.

Macronutrients
Carbohydrates
Carbohydrates are basically sugar molecule and based on structure they are divided in to two forms:
Simple carbohydrates and complex carbohydrates.
Simple carbohydrates are monosaccharides and disaccharides, whereas complex carbohydrates are oligosaccharides and polysaccharides.

Carbohydrates broken down to monosaccharides before absorption from the gut and supply energy. Actually carbohydrate should not be considered as an essential nutrient because they can be synthesized in the body from glycerol and protein. However if the available carbohydrate is less than 100 gram per day then increased lipolysis leads to ketosis.
Therefore sugar in original form (intrinsic sugar) as in fruits, vegetables and milk are never restricted but sugar is an extrinsic form should always be restricted.
Starches in cereal foods, root foods and legumes provide the largest proportion of energy in most diets around the world. Starches digested by amylase enzyme which is produced by pancreas and saliva, some starches digested by salivary amylase only and produce rapid delivery of glucose to the blood.
Carbohydrates source
Simple carbohydrates      Intrinsic: fruits, milks, vegetables
Extrinsic (extracted, refined): beet or cane sucrose,high fructose                                                                                                      corn syrup
Complex carbohydrates starch polysaccharides :(Rapidly digestible); cereals,whole                                                                                                     wheat, rice, root vegetables like potato
(Slowly digestible); lentils, legumes(peas,beans)

So bottom lines for carbohydrates are
1. Immediate source of energy or main fuel of body.
2. In case of starvation or going outside without carbohydrates or very less carbs, your body will use Glycogen as a fuel, glycogenolysis starts by using your protein from muscle mass and organs , gluconeogenesis starts (conversion of amino acids to glucose) to maintain normal glucose level in the body and the brain. So In starvation you are losing your muscle mass.
3. Carbs prevent ketosis – Even when fat is used for fuel, the cells need a bit of carbohydrate to completely break it down. Otherwise, the liver produces ketone bodies, which can eventually build up to unsafe levels in the blood causing a condition called ketosis. Ketosis can also cause the blood to become too acidic and the body to become dehydrated.

Fats
Fats are the highest energy density molecule; they provide most calories to the body
Dietary fat has a critical role in the body, one gram of fat provide 9 kcals, excessive consumption of fat may give rise to obesity and several diseases. But wisely use of fat is important to keep our body healthy.
Fats are different types like saturated fatty acid, unsaturated fatty acids (monounsaturated and Polyunsaturated Fatty Acids which is also called as PUFA).
Sources of Saturated fatty acids are animal fats butter, ghee or lard. Because your body can make all the saturated fatty acids it needs, you do not need any in the diet. High intakes of most saturated fatty acids are linked to high levels of LDL (low-density lipoprotein), or bad, cholesterol and reduced insulin sensitivity. Saturated fat and Trans Fat are associated with cardiovascular diseases so intake of these should be less than 2%. And replacing them with PUFA will reduce the risk of cardiovascular disorders.
Monounsaturated fat sources include avocados, nuts, seeds and olives. Peanut, canola and olive oils are additional sources.
PUFA are linoleic acid and Alpha linoleic acid which are essential fatty acids and sources are plant seeds oil. Other PUFAs are omega 3fatty acids and omega 6 fatty acids. Sources of omega 3 fatty acids are bluefish, herring, lake trout, mackerel, salmon, sardines, and tuna. Sources of omega 6 fatty acids are sunflower seeds, Brazil nuts, pecans and pine nuts. Some cooking oils are good sources too, such as corn, sunflower, safflower and sesame oils.
Hydrogenated oils, trans fats and saturated fats are not good for health, so try to reduce the intake of those and replace them with PUFA.

Proteins
Proteins are made up of 20 different amino acids, in which 9 are essential amino acids means they can not be synthesized in the body and we must get them through diet, we require them for our body growth, others are synthesized in the body by transamination. Proteins of animal origin, particularly from eggs, milk and meat, are generally of higher biological value than proteins of vegetable origin. However, when two different vegetable proteins are eaten together (e.g. a cereal and a legume), their amino acid contents are complementary and produce an adequate mix, an important principle in vegan diets.
Proteins in the body are constantly broken down and re-synthesized. Our bodies reuse most of the released amino acids, but a small portion is lost and must be replaced in the diet. The Recommended Dietary Allowance (RDA) for protein for adults is 0.8 g/kg of body weight. Because of their rapid growth, infants have the highest RDA for protein at 1.5 g/kg of body weight. The RDA gradually decreases until adulthood. It increases again during pregnancy and lactation to a level of 1.1 g/kg. The RDA for an adult weighing 140 pounds (63.6 kg) is a mere 51 grams of protein, an amount many of us consume before mid-afternoon. Usually people think that protein rich food is only animal derived, yeah definitely animal origin like meat,salmon, chicken, egg etc are rich in protein but vegetarians also get enough protein through legumes, cereals, beans, lentils, sprouts, nuts, peanut butter, broccoli, multigrain breads, cheese etc. If you eat a variety of foods, you will meet your protein needs.

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’sDavidson’s Principles and Practice of Medicine(22ndedition) http://www.naturalbalancefoods.com/community/dietary-needs/what-are-macronutrients-micronutrients/
http://www.innerbody.com/nutrition/macronutrients

 

Peptic ulcer Disease

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In common terms Ulcer means an open sore and word peptic is related to acid so Peptic ulcer means an open sore due to acid in Gastrointestinal tract.

In medical terms Peptic ulcer is an open sore which develops in the lining of gastro-intestinal tract that causes pain in stomach.

Peptic ulcers are of two types

1. Gastric ulcer – which is located in the inner lining of the stomach.
2. Duodenal ulcer – which is located in the duodenum or beginning of small intestine.

Both ulcers penetrate the muscularis mucosa but erosions do not penetrate the muscularis mucosa.
Peptic ulcer may be acute or chronic.

Pathophysiology

Peptic ulcers are defects in the gastric or duodenal mucosa that extend through the muscularis mucosa. The epithelial cells of the stomach and duodenum secrete mucus in response to irritation of the epithelial lining and as a result of cholinergic stimulation. The superficial portion of the gastric and duodenal mucosa exists in the form of a gel layer, which is impermeable to acid and pepsin. Other gastric and duodenal cells secrete bicarbonate, which aids in buffering acid that lies near the mucosa. Prostaglandins of the E type (PGE) have an important protective role, because PGE increases the production of both bicarbonate and the mucous layer.
In normal condition a physiologic balance exists between production of acid or diffusion of hydrogen ion and bicarbonates and production of protective mucus, when the balance between the aggressive factors (acid secretion) and the defensive mechanisms is disrupted, results in mucosal injury.

Aggressive factors

1. H. Pylori
Peptic ulceration is strongly associated with H. pylori (Helicobacter Pylori) infection.
These infections are probably acquired in childhood by person-to-person contact. The vast majority of colonized people remain healthy and asymptomatic and only a minority develops clinical disease.
H. pylori is Gram-negative and spiral, and has multiple flagella at one end, which make it motile, allowing it to burrow and live beneath the mucus layer adherent to the epithelial surface. H. pylori exclusively colonizes gastric-type epithelium and is only found in the duodenum in association with patches of gastric metaplasia. It causes chronic gastritis by provoking a local inflammatory response in the underlying epithelium.
In most people, H. pylori causes localized antral gastritis associated with depletion of somatostatin (from D cells) and increased gastrin release from G cells. Virulence factors produced by H pylori, including urease, catalase, vacuolating cytotoxin, and lipopolysaccharide, are well described.
The ulcer probably arises because of impaired mucosal defense resulting from a combination of H. pylori infection, NSAIDs and smoking, rather than excess acid.
2. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
Treatment with NSAIDs is associated with peptic ulcers. These are a group of pain-killer drugs which are most easily available drugs without prescriptions. Over uses of non-selective NSAIDs can damage the gastric and duodenal mucosal barrier and are associated with an increased risk of upper gastrointestinal ulceration, bleeding and perforation.
3. Smoking
Smoking and tobacco use is also associated with risk of developing duodenal and gastric ulcers. Once the ulcer has formed, it is more likely to cause complications and less likely to heal if the patient continues to smoke.
4. Alcohol intake
Drinking alcohol is also associated with gastric and duodenal ulcers. Ethanol is known to cause gastric mucosal irritation and nonspecific gastritis.
5. Severe physiologic stress
Stressful conditions that may cause PUD include burns, CNS trauma, surgery, and severe medical illness. Serious systemic illness, sepsis, hypotension, respiratory failure, and multiple traumatic injuries increase the risk for secondary (stress) ulceration.
Local radiation resulting in mucosal damage, which may lead to the development of duodenal ulcers
6. Sleep deprivation, sedentary lifestyle, eating habits, anxiety and depression are also common factors associated with peptic ulcer.

Signs and Symptoms

The most common symptom is recurrent abdominal pain which may be dull or sharp which has three important characteristics; localization to the epigastrium, relationship to food and episodic occurrence. Sometimes food makes the pain better, and sometimes it makes it worse. Other symptoms include nausea, vomiting, or feeling bloated or full. It is important to know that there are many causes of abdominal pain, so not all pain in the abdomen is an “ulcer”.
Sometimes in elderly people or the people taking NSAIDS for the years have no symptoms or very vague abdominal pain, these are silent ulcers and usually diagnosed first time when they develop anemia from undetected chronic blood loss.
Occasionally, the only symptoms are anorexia and nausea, or early satiety after meals.

Investigations

To know the cause of pain in abdomen your doctor may order the following tests
Testing for H pylori infection is essential in all patients with peptic ulcers.

1. Bood test – CBC count and Iron studies are useful to detect anemia. Anemia is an alarm signal for peptic ulcer disease and further investigations with endoscopy to rule out other disorders.
2. Liver function test, amylase and lipase may also be useful depending upon signs and symptoms.
3. Urea breath test – Urea breath tests detect active H pylori infection by testing for the enzymatic activity of bacterial urease. For a urea breath test, you will drink a special liquid that contains urea, a waste product that your body makes as it breaks down protein. If H. pylori are present, the bacteria will change this waste product into carbon dioxide and ammonia—a harmless gas. Carbon dioxide normally appears in your breath when you exhale.
In the presence of urease produced by H pylori, labeled carbon dioxide (heavy isotope, carbon-13, or radioactive isotope, carbon-14) is produced in the stomach, absorbed into the bloodstream, diffused into the lungs, and exhaled.
This test has high sensitivity and specificity but it needs expensive mass spectrometer.
4. Stool test – In the presence of H.pylori bacteria antigens can be seen on stool, also called as fecal antigen test. Fecal antigen testing identifies active H pylori infection by detecting the presence of H pylori antigens in stools. This test is more accurate than antibody testing and is less expensive than urea breath tests.
5. Endoscopy – Upper GI endoscopy is the preferred diagnostic test in the evaluation of patients with suspected PUD. It is highly sensitive for the diagnosis of gastric and duodenal ulcers, allows for biopsies and cytologic brushings in the setting of a gastric ulcer to differentiate a benign ulcer from a malignant lesion, and allows for the detection of H pylori infection with antral biopsies for a rapid urease test and/or histopathology in patients with PUD.
An upper GI endoscopy is performed by inserting a special lighted camera on a flexible tube into the person’s mouth to look directly into the stomach and the beginning of the small bowel. This flexible camera carefully inspects the most likely areas for ulcers to be located.

Treatment

The aims of management are to relieve symptoms, induce healing and prevent recurrence. H. pylori eradication is the cornerstone of therapy for peptic ulcers, as this will successfully prevent relapse and eliminate the need for long-term therapy in the majority of patients.

H. pylori eradication
The recommended primary therapy for H pylori infection is proton pump inhibitor (PPI)–based triple therapy. PPI and two antibiotics (from amoxicilline, clarithromycine and metronidazole) for 7 -14 days but high dose twice daily for longer duration (14days) is more effective, Amoxicillin should be replaced with metronidazole in penicillin-allergic patients only, because of the high rate of metronidazole resistance.
(PPI + Clarithromycine + Amoxicilline) PO twice daily for 14 days.
Or
(PPI + Clarithromycine +Metronidazole) PO twice daily for 14 days.
Quadruple therapy
Quadruple therapies for H pylori infection are generally reserved for patients in whom the standard course of treatment has failed. a quadruple therapy regimen, consisting of omeprazole (or another PPI), bismuth subcitrate, metronidazole and tetracycline (OBMT) for 10–14 days.
For those who are still colonised after two treatments, the choice lies between a third attempt guided by antimicrobial sensitivity testing, rescue therapy (levofloxacin, PPI and clarithromycin) or long-term acid suppression.

Maintenance treatment
Continuous maintenance treatment should not be necessary after successful H. pylori eradication. For the minority who do require it, the lowest effective dose of PPI should be used.

Surgical treatment
Surgery is now rarely required for peptic ulcer disease but it is needed in some cases.

General preventive measures

1. Unnecessary use of NSAIDS should be avoided.
2. Smoking is always dangerous for health, should be avoided.
3. Use of aspirin should be avoided.
4. Use acetaminophen or nonacetylated salicylates when possible.
5. Alcohol use should be avoided.
6. Follow healthy lifestyle.

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)
http://patients.gi.org/topics/peptic-ulcer-disease/
http://emedicine.medscape.com/article

Dysphagia/ Difficulty in swallowing

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Dysphagia means difficulty in swallowing. Dysphagia is a medical term used to describe swallowing disorder. Dysphagia is a symptom which is either alone as a single problem or it may be associated with heart burn, vomiting or pain.

Causes of dysphagia

Swallowing disorder/dysphagia can occur due to problems in oropharynx (Oropharyngeal dysphagia) or oesophagus (oesophageal dysphagia).

Oropharyngeal dysphagia – Swallowing disorder in which problem in initiation of swallowing at the level of pharynx and upper esophageal sphincter (opening of food pipe). Oropharyngeal dysphagia may be due to either functional or structural.
Functional means pharynx and esophagus are not functioning properly because of neuromuscular causes because the nerves controlling the muscles of the mouth, back of throat (pharynx) and opening of the esophagus (upper esophageal sphincter) have direct connections with the brain through cranial nerves, and can therefore be damaged in diseases involving the brain or cranial nerves. Neuromuscular disorder is the most common cause of oropharyngeal dysphagia.
Structural cause means narrowing of area or stricture formation, any swelling or lump/tumor obstructing from surrounding area.
Patients have difficulty in starting of swallowing and may complain of choking, nasal regurgitation or tracheal aspiration. Drooling, dysarthria, hoarseness and cranial nerve or other neurological signs may be present.

Esophageal dysphagia – Esophageal dysphagia may be due to either abnormality in esophageal normal peristalsis movement or structural disorder, narrowing of esophageus (food pipe) or obstruction in lumen. Narrowing of esophagus may be due to scarring due to acid reflux disease, inflammation of esophageal linings because of acid reflux, any obstruction in esophageal lumen either because of lump/tumor, or compression from surrounding area like any growth in chest or because of enlarged heart. Eosinophillic esophagitis is an inflammation in which inflammatory cells are all eosinophils.
Functional disorders of esophagus may be due to stiffening of esophageal muscles, weakness of esophageal muscles (Scleroderma), or disorder caused by nerve and muscle which affect relaxation of lower esophageal sphincter known as achalasia, esophageal spasm.
Patients with oesophageal disease complain of food ‘sticking’ after swallowing, although the level at which this is felt correlates poorly with the true site of obstruction. Swallowing of liquids is normal until strictures become extreme.
Achalasia, a condition where the esophagus fails to relax and allow food to pass, may be difficult to diagnose because symptoms progress slowly. In achalasia, difficulty may occur with both solids and liquids, and symptoms may be severe enough to cause weight loss. Patients with esophageal spasm can have chest pain as well.

Investigations

Dysphagia is a swallowing disorder which should be investigated urgently.

1. Signs, symptoms and medical history is very important to distinguish between esophageal or oropharyngeal dysphagia.
2. Endoscopy – Endoscopy (examination of the esophagus using a tube with a light and a video camera at the end) is the investigation of choice because This test not only allows the doctor to inspect the lumen and lining of the esophagus, but biopsy ( taking out samples of abnormal tissue for examination), can be done at same time and if appropriate, treatment can be performed by stretching out narrowed areas which is called as dilatation, so in short, it allows dilatation of strictures and biopsy.
3. Barium swallow with video fluoroscopic – If no abnormality found in endoscopy then Barium swallow with video fluoroscopic swallowing assessment is indicated to see whether there is any motility disorder.
In this procedure, patient swallows barium containing fluid and same time doctor observes the swallowing on X-ray screen to see swallowing functions of esophageal muscles and nerves.
4. Oesophageal high-resolution manometry – If a narrowing is not seen either on endoscopy or barium swallow, measurement of pressures within the oesophagus while swallowing sips of water (manometry) can help find out if the muscle of the oesophagus squeezes or relaxes abnormally while swallowing, and can diagnose conditions like achalasia or esophageal spasm.

1

Treatment

Treatment of dysphagia depend upon the cause of dysphagia,
If dysphagia caused by acid reflux disorder, eosinophillic esophagitis or any infection in esophagus then it can be completely resolve with the medicines.
If stricture or narrowing is the cause for dysphagia then endoscopic dilatation is the treatment but sometimes it may need repetitive dilatation or frequent sitting.
If achalasia is the cause of dysphagia then it can be treated with either surgery or endoscopic forceful dilation of lower end of esophagus.
When dysphagia is due to either obstruction or cancer growth then stent or tube is used to keep the esophagus open.

 

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), http://patients.gi.org/topics/dysphagia/

GOUT

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Gout is a form of inflammatory arthritis which is caused by deposition of monosodium urate monohydrate crystals in and around the synovial joints. This form of arthritis develops in people who have high level of uric acid in their blood (Hyperuricemia).
This is more commonly found in men than women. Risk of developing gout increases with age and increasing level of serum uric acid.

Risk factors for gout
1. Men – Gout has male preponderance, male to female ratio is 5:1. Gout is more commonly develop in men with age group between 40 and 50.
2. Women after menopause – Gout can develop in older women means after menopause increase risk of developing gout in women.
3. Person who has high level of uric acid in blood.
4. Family history – Usually many people having gout has the positive family history.
5. Medical conditions – people with some medical problems related with kidney, hypertension, diabetes, obesity and liver disorders are more prone to develop gout.
6. Metabolic syndrome
7. High alcohol intake
8. Generalized osteoarthritis
9. Diet high in red meat or fructose, low in vitamin C and coffee.
10.Lead poisoning

Causes of gout
We can divide the causes of increase level of uric acid in body in to three parts; decreased renal excretion or increased intake or overproduction of uric acid.
1.Decreased renal excretion because of
• Increased renal tubular reabsorption
• Renal failure
• Lead toxicity
• Lcatic acidosis
• Alcohol
• Drugs such as thiazide diuretics and loop diuretics, Aspirin, Cyclosporine and pyrazinamide
2.Increased intake
• Red meat
• Sea food
• Vegetables containing high purine content such as spinach, asparagus, peas, dried beans, cauliflower etc
3.Overproduction of uric acid
• Myeloproliferative and lymphoproliferative disorder
• Psoriasis
• High fructose intake
• Glycogen storage disease
• Inherited disorder; Lesh -Nyhan syndrome (HPRT mutations)

Signs and Symptoms
Gout has classic presentation of acute, sudden and severe pain in first MTP joint (big toe) usually come without warning, during the attack the joint or area becomes hot, red, swollen and extremely tender.
Most common joint involved is MTP, other sites are ankle, mid foot, knee, elbow, wrist.

Clinical features of pain

 Rapid and acute onset, reaching maximum severity within 2 – 6 hours.
 Pain usually awakens the patient in the early morning.
 Patient often describes it as worst pain ever.Pain feels like volcano fire
 Extreme tenderness, such that patient is unable to touch feet on the ground or anywhere, he can’t wear his socks on.
 Marked swelling with overlying red and shiny skin.
 Self-limiting, takes 10 -14 days in complete resolution
Apart from severe pain patient may have mild fever, malaise and confusion.

Gout may be
• Acute gout – Because of increasing level of uric acid, acute attack of severe pain is known as acute gout.
• Chronic gout – Chronic inflammation of one or more joints because of increasing deposition of uric acid crystals known as tophi.
Tophi may be deposited in joints and in soft tissues. Common places of deposition of tophi are extensor surfaces of fingers, hands, forearm, elbows, Achilles tendons and sometimes the helix of the ear. Tophi are white in color. Tophi can ulcerate, discharging white gritty material, become infected or induce a local inflammatory response, with erythema and pus in the absence of secondary infection.

How to diagnose?

Characteristic feature of pain usually indicate Gout but for confirmation and to rule out other types of arthritis some investigations are necessary.
 Aspiration of fluid from the joint space – Aspirate will show crystals of uric acid under microscope, bursa or tophi.
 In acute attack fluid shows increased turbidity due to high neutrophils.
 In chronic gout fluid may be white due to high crystal load.
 Blood test to measure high level of uric acids.
 Biochemical screen which include renal function test, lipid profile and uric acid to know any metabolic syndrome.
 Elevated ESR, CRP and neutrophilia in acute gout.
 Radiographs are usually normal in acute gout, but well demarcated erosions in patients with chronic gout or tophaceous gout may be seen.
 X ray, ultrasound and MRI are useful to see the soft tissue swelling and any destruction if it is.

Management

Aim of management is to relieve pain during gout attack and maintaining uric acid level below 6mg/dl by giving urate lowering drugs.
1. NSAIDS are simple pain reliever usually prescribed to relieve pain during acute attack of gout.
2. Local ice packs also suggested to relieve pain.
3. For recurrent episodes Colchicine is effective but it has some side effects such as nausea, vomiting and diarrhea.
4. Joint aspiration and intraarticular injection of steroids followed by early mobilization are very effective in acute attacks of gout.
5. Urate lowering therapy for patients who have high level of uric acid crystals with recurrent attacks of gout. Allopurinol is a xanthine oxidase inhibitor; starting dose should be 100mg per day and in older patients 50 mg per day. The dose of Allopurinol should be increased by 100mg every four weeks and 50 mg in elderly and those with renal impairment.
Febuxostat is a xanthine oxidase inhibitor which is useful in patients who fail to respond with allopurinol. Because of hepatic metabolism of this drug, no need to adjust the dose in patients with renal problems. It is more effective than allopurinol and starting dose is 80 mg per day.
6. Pegloticase is a biological treatment which is indicated for the treatment of tophaceous gout resistant to standard therapy and is administered as intravenous infusion every 2 weeks for up to six months. Side effects are infusion reactions (which can be treated by antihistamines and steroids) and flares of gout during first three months.
Annual monitoring of uric acid is recommended to prevent the attack of gout and to adjust the dose of urate lowering drug.

In addition to drug treatment predisposing /triggering factors should be avoided such as
 Drink plenty of water to remove uric acids from the body.
 Diet with high purine content should be avoided such as meats, seafood, vegetables like spinach, mushroom, asparagus, cauliflowers, oatmeal, dried beans, lentils, should be taken in limited amount.
 Alcoholic beverages should be avoided.
 Add low fat dairy products in your diet.
 Follow healthy lifestyle with diet plan and exercise. (Read health tips)

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(22nd edition), gout .com

Arthritis and Osteoarthritis

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Arthritis
Arthritis means inflammation of joints. Joint inflammation (redness or heat and swelling) is a sign and joint pain is a symptom. Arthritis is a common term used for any joint inflammation. There are more than 100 types of arthritis and related conditions. It can affect all age group, sex and races, arthritis is the leading cause of disability in America. Women and old age group individuals are affected most commonly.

Common symptoms of Arthritis
1. Joint pain
2. Swelling around the joint
3. Redness or hot joint (warmth)
4. Limited range of motion
5. Stiffness of the joint

These symptoms may be mild, moderate or severe. Symptoms may be persistent or come and go, when it gets progressively severe then it is difficult to move the joints or inability to move the joint or inability to walk.

Types of arthritis

There are more than 100 types of arthritis and related conditions, but most common types of arthritis are
Osteoarthritis
Rheumatoid arthritis
Gout

It is a vast topic so first I want to tell you about commonest type of arthritis “Osteoarthritis”

Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis. Most commonly it is associated with ageing and the major cause of joint pain in older people. Osteoarthritis is characterized by focal loss of articular cartilage, subchondral osteosclerosis, osteophyte formation or bone hypertrophy. Joint involvement in Osteoarthritis follows a characteristic pattern Hip joint, knee-joint, joints in hands, neck and then spine. Knee and hip-joint involvement are most common in women with age group 45 to 65.

Pathophysiology

Normal joints have little friction with movement and do not wear out with overuse or trauma. In joints cartilage has the very important role which is made up of matrix or fluid (around 80%), solid phase collagen and protein (around 18%) and cells (chondrocytes around 1-2%). Under normal condition there is a balance between matrix and enzymatic activities of cartilage in dynamic remodeling of collagen but in osteoarthritis increase degradation of major structural components of cartilage occurs because of overexpression of degrading enzymes leads to loss of collagen and proteoglycans from matrix, which makes cartilage more vulnerable to load bearing injury.

Because of this slow destruction of cartilage in the form of fibrillation/fissuring occurs which leads to vertical cleft formation, chondrocytes death and thus leads to decreased cartilage thickness which is usually focal and mainly affects the weight-bearing joints.

Loss of cartilage leads to sclerotic bone formation and often deposition of calcium pyrophosphate and calcium phosphate crystals in the abnormal cartilage.

Subchondral bone stiffens, then undergoes infarction, and develops subchondral cysts. Fibrocartilage is produced at the joint margin, which undergoes endochondral ossification to form osteophytes. Bone remodeling and cartilage thinning slowly alter the shape of the OA joint, increasing its surface area.
In attempt to repair bone and stabilize the joint subchondral sclerosis and osteophytes formation occurs. The synovium undergoes variable degrees of hyperplasia, and inflammatory changes which causes synovial fluid less viscous with greater volume, although to a much lesser extent than in RA and other inflammatory arthropathies.

In simple words osteoarthritis is a process of progressive cartilage matrix degradation to which an ineffectual attempt at repair is made.

Risk factors in Osteoarthritis
1. Heredity – Osteoarthritis associated with heredity and some genetic factors.
2. Gender – Women more commonly have osteoarthritis than man. The cause behind this may be associated with hormones and sex hormones.
3. Obesity – Obesity is a very important risk factor in osteoarthritis, so most common joint involvement in obese women is knee and hip (weight bearing joints)
4. Age – Age is most consistently identified risk factor of Osteoarthritis. More commonly men after 50 and women after 40 may suffer with osteoarthritis.
5. Trauma – Repetitive injury may cause cartilage destruction and related injuries may lead to osteoarthritis.
6. Occupation – Farmers, sport and some occupation related to repetitive friction on joints may also cause osteoarthritis.

Signs and Symptoms
The main presenting symptoms are pain and restriction of movement of involved joint. The cause of pain in osteoarthritis is not completely understood but may be because of weight-bearing and pressure on joints so commonly cause “Night pain”.
 Pain may be gradual and slow in onset and may become consistent after long time.
 Pain may be variable or intermittent ( some days are pain-free, good days but some are bad days with pain)
 Pain is mostly related to activity, movement or weight-bearing (standing or walking for long time or most of the time in a day), relieved by rest.
 Usually only one or few joints painful.

Signs
• Restricted movement of joint due to stiffening of joint, capsular thickening and bone hypertrophy
• Palpable, sometimes patient can also hear sound (crepitus) during movement of joint due to rough articular surface.
• Bony swelling around joint margins.
• Deformity, without instability
• Tenderness on palpation at joint line.
• Surrounding muscle weakness
• Synovitis usually mild.

Osteoarthritis can be localized; only in one joint or it can be generalized.
Joints commonly affected in generalized osteoarthritis are
• Distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints (causing Heberden and Bouchard nodes)
• Thumb carpometacarpal joint
• Intervertebral disks and zygapophyseal joints in the cervical and lumbar vertebrae
• First metatarsophalangeal joint
• Hip
• Knee

Generalized nodal OA has a very strong genetic component; the daughter of an affected mother has a 1 in 3 chance of developing nodal OA herself. People with nodal OA are at increased risk of OA at other sites, especially the knee.

Knee OA
Usually involve patellofemoral and medial tibiofemoral compartment but may affect the whole joint.
The pain is usually at anterior and medial side, posterior knee pain suggests popliteal cyst (Baker’s cyst).

Hip OA
Targets the superior aspect of joint, usually unilateral and involvement of superolateral femoral head makes it worse with poor prognosis. The central or medial osteoarthritis is less common with good prognosis and confined to women.

Spine OA
The cervical and lumbar spine are predominantly targeted by OA, and referred to as cervical spondylosis and lumbar spondylosis, respectively. The typical presentation is with pain localized to the low back region or the neck, although radiation of pain to the arms, buttocks and legs may also occur due to nerve root compression. Pain is typically relieved by rest and worse by movement.

Erosive OA
Typically patients with hand OA who have a more prolonged symptom phase, more overt inflammation, more disability and worse outcome than those with nodal OA.

Investigations

X- RAY – Plain X ray of the affected joint is performed, typical features of Osteoarthritis can be seen like narrowing of joint space, bone remodeling, subchondral cyst formation or effusion.
In case of spine osteoarthritis to see the nerve compression MRI should be performed.
Routine biochemistry, hematology and autoantibody tests are usually normal.
Synovial fluid analysis required to rule out other related disorder.

Management
1. Education and supportive measures
2. Pharmacotherapy

1. Education and supportive measures

It is very important to know the nature of condition, so you can ask to your physician in detail about the condition. Knowledge about the risk factors and treatment is also very important.

Weight loss – If patient is overweight than weight reduction is very important to relieve pain specially in lower limbs because weight bearing joints are more prone to get osteoarthritis.
Exercise – Exercise has beneficial effects in OA, including both strengthening and aerobic exercise, preferably with reinforcement by physiotherapist. Aquatic exercises also recommended to relieve the stress.
Shock-absorbing footwear, pacing of activities, use of a walking stick for painful knee or hip OA, or provision of built-up shoes to equalize leg lengths can all improve symptoms.
Change in lifestyle also recommended, taking rest for few minutes in between work.

2. Pharmacotherapy

If symptoms do not respond to general and supportive measures than analgesics and anti-inflammatory drugs should be use.
Topical NSAIDS can be use first but for patients who are symptomatic for long time oral analgesic (NSAID) and then capsaicin should be use.
In severe cases sometimes opioids can be use.
Corticosteroid injection
Intraarticular corticosteroid injections are very effective in treatment of knee osteoarthritis. Duration of effect may be three to six months, so in constant and severe pain repetitive injections can be given depending upon preparation.
Chondroitin and glucosamine
Chondroitin sulphate and glucosamine sulphate have been used alone and in combination for the treatment of knee OA.
Hyaluronan injections
In knee OA, intra-articular injection of one of several forms of hyaluronan (polymers of hyaluronate), usually given as a course of weekly injections for 3–5 weeks, may give modest pain relief for several months. But because of repetitive injections and low efficacy these are usually not recommended.

Surgery

Surgery should be considered for patients with OA whose pain, stiffness and reduced function impact significantly on their quality of life and are refractory to other treatments. Total joint replacement surgery is by far the most common surgical procedure for patients with OA. Surgery is indicated when there is significant structural damage on X-ray and functional impairment affecting the quality of life and if all nonsurgical measures fail. Surgical options include arthroscopy, osteotomy and arthroplasty.

Coming up next – Crystal induced arthritis /Gout

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
http://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/joint-disorders

 

Allergy

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What is allergy?

Allergy is an abnormal autoimmune response of the body’s defense mechanism with any foreign substance. In simple words allergy is hypersensitivity of the immune system to any foreign substance which can be different in different people such as
Dust
Pollen
Insect stings
Pet dander
Food items
Latex
Drug/medicine
Mold
All these are also types of allergies and these substances called as allergen.

Signs and Symptoms
If you come in contact with something to which you are allergic, your immune system considers it dangerous and releases chemical called histamine to counteract it. The release of histamine can cause a variety of symptoms, including
Skin rash,
Headache,
Sneezing,
Runny nose,
Swelling,
Nausea and
Diarrhea
Though some symptoms are common in any types of allergy but few symptoms depend upon the allergen or the substance you are allergic with.
Anaphylaxis is type of severe allergic reaction which can be dangerous or life threatening; symptoms include low blood pressure, low pulse, shortness of breath, wheezing, blurred vision and collapse.

1. Dust allergy
If you are allergic with dust or pollen or dander which you can breathe in may cause following symptoms
Itchy eyes, redness in eyes, watery eyes, painful eyes, sneezing, itching and irritation in and around the nose, runny nose or stuffy nose due to blockage or congestion, coughing, sore-throat, shortness of breath, headache ( commonly called as allergic rhinitis/hay fever).
Allergic rhinitis takes two different forms:
Seasonal: Symptoms of seasonal allergic rhinitis can occur in spring, summer and early fall. They are usually caused by allergic sensitivity to airborne mold spores or to pollens from grass, trees and weeds.
Perennial: People with perennial allergic rhinitis experience symptoms all over the year. It is generally caused by dust mites, pet hair or dander, cockroaches or mold. Underlying or hidden food allergies rarely cause perennial nasal symptoms.

2. Stings allergy
If allergen comes in contact with skin (stings) swelling, rashes, hives, itching with common allergic symptoms may occur.

3. Food allergy
Common Allergen food items are peanuts, eggs, milk, wheat, fish and soy.
If allergen is food item then nausea, vomiting, diarrhea, abdominal pain, shortness of breath may occur.

4. Mold Allergy
Mold is a fungus, which can grow in any moisture area, bathroom, basement, any closed room, unused clothes for long time and places with lack of sunlight. Molds are tiny and most of the time can’t be seen through naked eyes, spores from molds get in contact with air and therefore give allergic reactions like sneezing, coughing, runny nose or stuffy nose, itching around eyes and nose, may be itching and rashes on skin, difficulty in breathing or wheezing.

5. Drug allergy
Common drug allergens are penicillin and related antibiotics, sulfa drugs, aspirin, ibuprofen, anticonvulsants, chemotherapy drugs, some dye containing drugs.
Allergic reactions include skin rashes, swelling, hives, shivering, or sweating, low Blood pressure, low pulse, wheezing, and may be anaphylaxis reactions.

6. Latex allergy
Usually health care workers and people having multiple surgeries are at greatest risk with latex containing gloves. This may be serous and fatal. Symptoms may be skin rashes, swelling, hives, itching, wheezing, shortness of breath, asthma symptoms or anaphylaxis reaction.

7. Pets /animal dander allergy
This type of allergy also has the common symptoms like sneezing, runny nose, nasal congestion, itchy eyes and nose, red eyes, coughing, sore throat, wheezing.
Sometimes allergy symptoms can be very severe and turn in to anaphylactic reactions, so be very careful if you are having any allergy.

Diagnosis
If you are having any of these symptoms with contact of allergen and you are thinking that you may have allergy with any of these then you can go to your health care provider, he will ask you questions about your routine, your work and home environment, detailed medical history, family history, frequency and severity of symptoms, and exposure to common triggers.
For confirmation of trigger of allergic reaction he may order for Skin prick test in which using a small, sterile probe to prick the skin with extracts from common allergens, such as tree pollen and pet dander, and observing the reaction A positive reaction (a raised welt with redness around it) may indicate that you are allergic to that substance. Occasionally, your allergist may order a blood test and a skin test to confirm an allergy.

Management and treatment
The best way to manage allergy problem is the prevention, which is avoidance of allergen.
If you know that you are allergic with particular substance you should avoid to come in the contact with allergen.

Dust allergy
Air born allergies like dust, pollen, animal dander, molds have common symptoms and triggers.
1. Avoid going to the places rich in dust, pollen or animal dander, molds.
2. Clean your home with central vaccuming and use mask while dusting.
3. Use mite proof blankets and mattresses.
4. Wash all bed linens regularly.
5. Choose the room with proper sunlight.
6. Keep windows closed during high pollen periods.
7. Use sunglasses or eyeglasses to protect eyes from dust, pollen and dander.
8. Keep pets out of the room all time.
9. Use high efficiency air filter to clean the whole house.
10.If you are living in humid or sticky climate, use dehumidifier.
11.Use vent fan in kitchen and bathroom to remove moisture.
12.Stay away from smoke and smoking

Food allergy
If you have food allergy and you know about triggering food causing allergy then NEVER EAT the trigger food item.
When you are eating outside, in restaurant be extra careful, and tell to all your friends and group about your allergic food item. Use clean dishes which are not in contact with allergen.

Stings allergy
1. For outdoor activities wear full sleeve and completely covered body clothes.
2. Do not walk barefoot on the grasses, do not go near bushes.
3. Be careful around nest areas.

Drug allergy
Make sure that your doctor or health care professional knows about your allergy and symptoms in detail.
Avoid any combination of related drug.

Latex allergy
Avoid latex containing gloves.

TREATMENT
1. Antihistamines to counteract allergic reactions
2. Decongestants help relieve nasal stuffiness and pressure caused by swollen nasal tissue.
3. Non steroidal anti inflammatory drugs (NSAIDS) to reduce inflammation or swelling.
4. Allergy shots (immunotherapy)
5. Epinephrine/Adrenaline injection.
People can carry epinephrine auto injectors for stings and food allergy or severe allergic reaction.

So basically allergy is an immune response, if you are having strong immunity probably you will not suffer any immunity related problems but because of weak immunity you can suffer from so many problems. The best way to improve immunity is the yoga and meditation; if you are suffering from any allergic problem you should follow healthy lifestyle with yoga (pranayama) regularly. Deep breathing exercises or pranayama rejuvenates your inner energy and boost up your brain with balancing all the chemicals and hormones in the body. So hormones and chemicals releasing during immune response can be controlled by yoga and meditation.

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  –  www.acaai.org  American College of Allergy, Asthma & Immunology

 

PCOS/PCOD/Polycystic Ovarian Syndrome

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Polycystic Ovarian Syndrome or PCOS is a hormonal endocrine disorder of ovary in women in all over the world. Other name for PCOS is Stein-Leventhal Syndrome. As the name indicates multiple cysts in the ovary is called polycystic ovary syndrome, and the size of ovaries in women with PCOS are 2 to 5 times the normal size.
Undiagnosed and untreated PCOD is a leading cause of female infertility. PCOS affects 4 to 6% of women, the full-blown syndrome of hyperandrogenism, chronic anovulation and polycystic ovaries. Because of wide variety of clinical symptoms and biochemical features exact definition of Polycystic Ovary Syndrome is least understood and can be confusing. According to Rotterdam criteria definition of PCOS contains two out of three following criteria:
1. Oligomenorrhea or Anovulation
2. Hyperandrogenism (clinical/biochemical)
3. Polycystic ovaries with exclusion of other etiologies.

Hormonal and biochemical changes are responsible for PCOS symptoms. There may be abnormality in the four active compartments: a) ovary, b) hypothalamus-pituitary compartment, c) peripheral fat or d) adrenal glands. Abnormality in ovarian compartment is responsible for hyperandrogenism in PCOS. Ovaries in women with PCOS are 2 to 5 times the normal size.

Hormonal changes in PCOS
1. Hyperandrogenism – Increased level of total and free testosterone.
High intraovarian androgen concentration inhibits follicle maturation results in inactive granulosa cells with minimal aromatase activity for conversion to estrogens.
2. Increased LH without increase in FSH leads to Increase LH/FSH ratio.

Clinical symptoms

1. Menstrual dysfunction – From amenorrhea to oligo menorrhea. Menarche tends to be delayed, irregular menstrual cycles or 4 to 6 menstrual periods per year.
2. Acne – Severe acne in teenage years is very common finding of PCOS.
3. Obesity – About 50 % women with PCOS found obese. Obesity in PCOS linked to insulin resistance, diabetes mellitus and increased risk of cardiovascular disease in later life.
4. Hirsutism – Excess hair growth on the face and body.
5. Alopecia – Hair loss and male pattern baldness.
6. Acanthosis nigricans – Hyperpigmentation of the skin.
7. Infertility – Infertility is the common problem in PCOS women.

How to Diagnose?

1. Symptoms and clinical features are most important in early diagnosis. Patient gives history of irregular menstruation, acne, excess facial hair growth and weight gain (high BMI). During reproductive age women may have history of infertility.

2. Laboratory tests – Blood tests to know the level of some hormones, Blood sugar, Insulin and IGF 1, cholesterol and triglycerides level in PCOS women.
Criteria for metabolic syndrome in PCOS women
• Abdominal obesity (waist circumference >88 cm or 35 inches)
• Triglycerides >150 mg/dl
• HDL-C <50 mg/dl
• Blood pressure > 130/85
• Fasting blood sugar of 110-126 mg/dl and 2-hour glucose from oral glucose tolerance test of 140-199 mg/dl

3. Ultrasonography – Ultrasonographic examination is a useful method for early detection of PCOS and follow-up. Generally, ovarian size is increased. The most important ultrasonographic finding is a bilaterally increased number of microcysts measuring 0.5 to 0.8 cm with generally more than five microcysts in each ovary.

Management

The management of PCOS depends upon clinical symptoms and presenting problems.

Menstrual irregularities
1. Weight loss – In obese women weight loss should be the first line of treatment. A reduction in body weight of 5-10 per cent will cause a 30 per cent reduction in visceral fat, which is often sufficient to restore ovulation and reduce markers of metabolic disease.
2. Oral contraceptives – Often OCPs can have the benefits of contraception, protection against endometrial cancer and improve skin manifestations such as acne and hirsutism.

Acne
Mild acne can be treated topically with keratinolytics such as azelaic acid, retinoids or with antibacterials erythromycin 2 % gel or clindamycin 1 % lotion. Severe forms can be treated by oral antibiotics or isotretinoin.
But in PCOS antiandrogens are most effective because acne occurs as a result of hyperstimulation of sebaceous glands by androgens. Cyproterone acetate, Spironolactone Flutamide and Finasteride have antiandrogenic properties. Cyperoterone acetate can be combined with OCPs.

Hirsutism
Hirsutism can be treated by physical therapy such as bleaching, shaving, plucking, depilatory creams or electrolysis and laser. Combined Oral contraceptive is useful for prevention of excess hair growth.

Alopecia
Psychological supports and hairstyling are the treatment for alopecia. Drugs such as minoxidil, cyproterone acetate, spironolactone has limited role.

Infertility
Main cause of infertility in PCOS is anovulation. So methods of inducing ovulation are reduction of insulin concentrations, FSH (follicular stimulating hormone) stimulation and reduction in LH (luteinizing hormone) concentration.

Weight loss
Weight loss is the mainstay therapy for induction of ovulation. Weight loss improves endocrine profile and the likelihood of ovulation and a healthy pregnancy. Diet plan and exercises should be encouraged.

Clomiphene citrate
Clomiphene citrate 50 mg orally for 5 days is a common method to induce ovulation. Serial transvaginal ultrasound is used to look for follicles or urinary LH test can also be done to know fertile period.

Metformin
For treating hyperinsulinemia in PCOS women Metformin 500 mg 8 hourly is an effective treatment.
In patients who do not ovulate with clomiphene citrate and metformin, doctor can advise for laparoscopic ovarian drilling or parenteral gonadotrophic therapy.

Laparoscopic ovarian drilling
Laparoscopic ovarian drilling is a simple procedure whereby several punctures are made in one or both the polycystic ovaries.

Gonadotropin therapy
Gonadotrophin therapy is indicated for women with anovulatory PCOS who have been treated with antiestrogens, either if they have failed to ovulate or if they have a response to clomiphene that is likely to reduce their chance of conception. Patients are started with very low dose gonadotrophin (FSH) and the dose is gradually increased. When the leading follicle reaches 14 mm, the FSH threshold dose is reduced by half.
In some patients, invitrofertilisation (IVF) or even intracytoplasmic sperm injection (ICSI) may be the only option for pregnancy.

Complications

PCOS patients are increased risk of developing chronic diseases which are directly linked to obesity in PCOS.
Non-insulin dependent Diabetes mellitus (NIDDM)
Cardiovascular diseases such as hypertension and coronary heart disease
Endometrial cancer
Infertility
Depression and anxiety

Because of the risk of chronic disorders, PCOS patients are advised to continue follow-up every 6 months.

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 – Jeffcoate’s Principles of Gynaecology 7th edition

GERD / Heartburn /Regurgitation/Indigestion

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What is GERD?
Gastroesophageal reflux disorder is reflux or regurgitation of acid content or bitter fluid from the stomach to the esophagus. Most common words used for GERD are heartburn, indigestion, acid reflux and acid regurgitation. It can affect individual’s quality of life so do not ignore if you are having this problem.

Symptoms of GERD
GERD presents with acid content or bitter taste in mouth usually after meals, on lying down or with bending, straining or heavy lifting. GERD often accompanied with other symptoms such as;
• Heartburn or burning sensation or heaviness around middle of the chest or upper abdomen
• Nausea
• Vomiting
• Halitosis or bad breath
• Difficulty in swallowing or pain during swallowing.
• Dry, long-lasting cough with sore throat.
• Wearing away of your teeth/erosion of enamel of your teeth.

Causes of GERD
GERD means acid content coming back up to the esophagus or food pipe. Actually when we swallow food it comes from esophagus to stomach. At the lower end of esophagus there is a band of muscles called as lower esophageal sphincter (LES) which plays an important role in preventing acid reflux from the stomach means it acts as a barrier between lower part of esophagus and stomach. When lower esophageal sphincter relaxes it allows food to enter in to the stomach and then it closes to prevent food particles and acidic content to flow back in to the esophagus, but if there is weakness in the muscles of lower esophageal sphincter it may relax at inappropriate time when actually it should not and causing stomach contents to rise up in to the esophagus. Factors like distention of the stomach, delayed emptying of the stomach, large sliding hiatal hernia, or too much acid in the stomach can also make it easier for acid reflux to occur.

Risk factors of GERD
1. Obesity – Increased weight may cause increase pressure on the abdomen and may causes relaxation of LES at inappropriate time.
2. Pregnancy – In pregnancy due to high progesterone level motility of entire gastrointestinal tract decreases and LES relaxation leads to acid regurgitation and heartburn.
3. Smoking – smoking and passive smoking also relaxes LES leads to acid regurgitation.
4. Certain medications- antihistamines, analgesics, antidepressants, Calcium channel blockers used to treat high BP, Asthma medications eg bronchodilators and theophylline, sedatives, antibiotics and estrogen replacements.
5. Sedentary lifestyle – People who work as sitting for long, do not do any physical activity and late night work or not sleeping in the night increases acid content of stomach.
6. Wrong dietary habits – Oily and spicy food, junk food, chocolates, peppermints and alcoholic beverages increases acid content of stomach and weakens LES.
7. Low gap between meal and sleep – Ideal time gap between meal and sleep (going to bed) should be at least 3 hours but reduced time gap or going to bed just after meal decreases digestion process and increases acid content of stomach.
8. Hiatus hernia – Hiatus hernia is a condition in which the opening in your diaphragm lets the upper part of the stomach move up into your chest, which lowers the pressure in the esophageal sphincter.

Even when the LES and the diaphragm are intact and functioning normally, reflux can still occur. The LES may relax after having large meals leading to distension of the upper part of the stomach. When that happens there is not enough pressure at the LES to prevent reflux. In some patients the LES is too weak or cannot mount enough pressure to prevent reflux during periods of increased pressure within the abdomen.

When you need to go to the doctor
If you are having acid reflux or heartburn twice in week for few weeks, accompanied by other symptoms like nausea, vomiting, abdominal pain, bad breath, chronic dry cough, sore throat then you should take an appointment with your doctor.

Diagnosis
1. Signs and symptoms, medical history, medication history, family history, lifestyle and dietary habits, and physical examination are important to diagnose GERD.

If patient has chronic heartburn, symptoms are not improving, trouble in swallowing then doctor can order few of these diagnostic tests and may refer the patient to gastroenterologist.

2. Ambulatory 24 hour acid pH probe test – It is a test to monitor the amount of acid in your esophagus. This is the most accurate procedure to detect acid reflux. A gastroenterologist performs this procedure at a hospital or in outpatient care as a part of an upper GI endoscopy. A thin tube with pH sensor passed through the patient’s nose or mouth in to the esophagus which measures how much and how many times stomach regurgitates acid, other part of tube is connected to the computer which records the pH readings. Monitoring is for 24 hours.

Bravo wireless esophageal pH monitoring – This is also for pH monitoring but in this the doctor temporarily attaches a small capsule to the wall of your esophagus during an upper endoscopy. The capsule measures pH levels in the esophagus and transmits information to a receiver. The receiver is about the size of a pager, which you wear on your belt or waistband. You can follow your usual daily routine during monitoring, which usually lasts 48 hours. The receiver has several buttons on it that you will press to record symptoms of GERD such as heartburn. The nurse will tell you what symptoms to record. You will be asked to maintain a diary to record certain events such as when you start and stop eating and drinking, when you lie down, and when you get back up. Before this procedure your doctor will ask to stop all GERD medications if you are taking any. After about 5 to 7 days capsule will fall off and pass through the stool.

3. Upper GI endoscopy and Biopsy –Procedure performed by surgeon or gastroenterologist in the hospital usually under sedation. Endoscope is a thin flexible tube fitted with camera to see inside the organs. Doctor carefully feeds the endoscope in to the upper gastrointestinal tract (esophagus, stomach and duodenum) to examine and if need to take small sample of tissue (biopsy) for further examination.

4. X-ray images of Upper GI – Upper GI series usually performed by X -ray technician at hospital or outpatient center. Patient is asked to drink barium to coat the inner lining of your upper GI tract. With help of barium (contrast) X-ray doctor can detect hiatal hernia, esophageal stricture, ulcers or any other problem.

5. Esophageal manometry – Esophageal manometry measures muscle contractions in your esophagus. A gastroenterologist may order this procedure if you’re thinking about anti-reflux surgery.

Treatment
Depending upon signs and symptoms doctor may recommend naturotherapy, pharmacotherapy or surgery.

Naturotherapy
1. Lifestyle change – If you have sedentary life style, change it and try to walk every day for 30 min and in the sitting job try to walk after each meal and after every 2 hours for 5-10 min.
2. Dietary habits – Avoid caffeine, avoid spicy, fatty and junk food and alcoholic beverages. Increase intake of fibers, fruits and fresh vegetables. Do not overeat. Healthy breakfast is must to prevent acid reflux.
3. Meal time – You should follow a strict pattern of meal time. Last meal of the day should be at or around 7 pm, so that you can have time gap between meal and sleep at least 3 hours. Do not go on the bed just after a meal.
4. Sleeping habits – Always try to go to bed around 9 pm- 10 pm and minimum 6 hours sleep is very important for healthy life. Sleep on a slight angle. Elevate the head of your bed 6 to 8 inches by safely putting blocks under the bedposts.
5. Quit smoking – smoking increases acid production and quitting smoking will prevent from cancer and many diseases.
6. Stop taking over the counter available analgesics and medicines which can increase acid production.
7. Weight loss- if you are overweight or obese try to loose your weight to prevent obesity related disorders.
8. Aloevera – Aloevera soothes the burn or inflammation, so drinking aloevera juice is beneficial in GERD.
9. Banana and apple are natural antacids.
10. Avoid tight-fitting clothes.
Follow healthy lifestyle and Health tips.

Pharmacotherapy
1. Antacids to relieve heartburn and other mild symptoms. Antacids are available over the counter are Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and Tums, may provide quick relief. But antacids alone will not heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation.
2. H2 blockers decrease acid production. H2 blockers are Ranitidine (Zantac 75), Cimetidine (Tagamat HB), Famotidine (Pepcid AC), Nizatidine (Axid AR).
3. PPIs(Proton pump Inhibitors) limit acid secretion in the stomach and resolution of the symptoms with healing of the esophagus. Over the counter available PPIs are Omeprazole (Prilosec),lansoprazole, pantoprazole(protonix), rabeprazole(Acip Hex), esomeprazole (Nexium)
4. Prokinetics help the emptying of stomach faster. On prescription metoclopramide(reglan), Bethanechol (Urecholine)

Surgery
Though most of the time GERD improved and relieved by medications but if symptoms are not improving with medications and lifestyle change, doctor may advice for surgery.

Fundoplication – For long-term reflux prevention Nissen fundoplication is the most common surgery. Surgeon perform this at the hospital under anesthesia by using laparoscope, which is a thin tube fitted with video camera. Fundoplication is a procedure to tightening the lower esophageal sphincter by wrapping the top of the stomach. Hospital stay usually 2-3 days. Return to normal daily activities in 2 weeks.

Using LINX – Linx is a ring-shaped magnetic titanium based device which is used to wrap around lower esophagus and top of stomach to tighten the lower esophageal sphincter. Because of the strong magnetic attraction between titanium beads in the ring it prevents opening during acid reflux.

Complications Of untreated GERD
Respiratory problems – Because of acid reflux in GERD sometimes during sleep acid can go in to the lungs which cause respiratory problems.
Dry and long-lasting cough or sore throat
Chest congestion or fluid in the lungs (Aspiration Pneumonia)
Hoarseness of voice
Wheezing
Laryngitis
Esophagitis – It is inflammation of esophagus because of destruction of normal esophageal lining by acid. If left untreated chronic esophagitis may be cancerous.
Esophageal stricture- In this esophagus becomes narrow.
Barrett’s esophagus – Untreated GERD may sometimes give rise to a serious condition like barrett’s esophagus which is cancerous.

Key point to remember
Heartburn due to GERD and chest pain due to angina (reduced blood supply to the heart) or heart attacks are similar. GERD related heartburn usually after heavy meal or spicy food and gets worse by bending or lying down. Chest pain or discomfort due to angina usually after exertion or emotional stress and not affected by changing in the positions and gets worse after physical activity and does not go away with rest.If you are not sure visit to the doctor without delay.

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.

Source content – The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), International Foundation for Functional Gastrointestinal Disorders aboutgerd.org

Acne or Pimples

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Acne or commonly known as pimples are very common skin problem in teenage and late teenage groups, though any age group from newborn to adults or sometimes older people can also have acne, usually women complains about acne but common in men too. Acne has negative effects on selfesteem due to cosmetic reason and it gives scars when goes off.
Acne is a chronic inflammation of pilosebaceous units (hair follicles and accompanying sebsceous glands) due to increased sebum production. Acne may present as various forms include seborrhea, comedones, papules, pustules, nodules, pseudocyst and after that scars when acne goes off.

Pathogenesis
There are four major pathogenic factors in the development of acne
1. Increased sebum production
2. Follicular hyperkeratinization (follicular plugging with sebum and keratinocytes)
3. Propionibacterium acne (P. acne) colonization
4. Release of multiple inflammatory mediators

Factors that may cause acne
Severity of acne depends upon sebum excretion rate which increases in puberty. There are multiple factors which can cause acne.
1. Hormonal factors – Sex hormones androgens, progesterone and testosterone increases sebum production rate. At puberty, level of these hormones increases thus cause acne formation. Estrogen reduces sebum production. But most patients have normal hormone profiles.
2. Genetic factors – sometimes if anyone in family had bad acne that may run in to family.
3. Environmental factors – high humidity, heat and sweating may also cause acne.
4. Stress and depression – Psychological stress and depression may disturb the hormonal level and may cause acne.
5. Lack of sleep – Insufficient sleep also stimulates sebum production and acne formation.
6. Certain cosmetics which contain lanolin, vegetable oils, butyl sterate or lauryl alcohol and oleic acid are another cause of acne.
7. Some products which are irritants on skin or allergic to skin also cause acne.
8. Dietary habits – High intake of dairy products, meat, sugars, junk food also cause acne.
9. Hair dandruffs also cause acne so hair washing frequently advised to prevent acne.
10.Certain medications also provoke acne.

Signs and symptoms
Local symptoms are pain tender and erythema. Acne vulgaris typically affects the areas of skin with the densest population of sebaceous follicles (eg, face, upper chest, back). Acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease.
Acne or pimples may be in different forms
Comedones are sebaceous plugs impacted within follicles. Depending on wheather follicle is closed or dilated(open) at skin suface comedones are of two types closed comedone or whiteheads and open comedones also called blackheads.
Plugs are easily extruded from open comedones but are more difficult to remove from closed comedones. Closed comedones are the precursor lesions to inflammatory acne. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter; blackheads (open comedones) are similar in appearance but with a dark center.
Papules and pustules are inflammatory acne, usually occurs after propionibacterum acne colonization in closed comedones, these are red lesions around 2-5 mm in diameter, papules are relatively deeper and pustules are superficial.
Nodules or small eruptions which are solid and painful. Cysts are suppurative nodules.
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Acne fulminans – It is rare but severe presentation usually associated with fever, joint pain and swelling. It is usually found on the trunk.
Acne Conglobate – Severe acne, characterized by multiple comedones, nodules, abscess, sinuses, cysts and marked scarring without the presence of systemic symptoms. More commonly present in adult males on the trunk and upper limb.
Acne Excorii- Self inflicted excoriation of skin due to repetitive touching , picking and pricking of preexisting acne lesions. Most commonly presents in teenage girls and people suffering with psychological stress or depression.
Pyoderma faciale (also called rosacea fulminans) – occurs suddenly on the midface of young women. The eruption consists of erythematous plaques and pustules, involving the chin, cheeks, and forehead.
Secondary acne– acne caused by either greasy or irritant cosmetics, exposure to oil and dust or some medications like corticosteroids, anticonvulsants, lithium. Polycystic ovary syndrome, menstrual irregularities and premenstrual period are usually associated with acne.

Diagnosis
Signs and symptoms along with medical history, menstrual history, any medications, psychological stress or depression and environmental history.
Local examinations of acne and scars
Laboratory tests for female menstruating patients to check hormone levels of total and/or free testosterone, dehydroepiandrosterone sulfate, luteinizing hormone (LH), and follicle-stimulating hormone (FSH).

Treatment
It is important to treat acne to reduce the extent of disease, scarring, and psychological distress.

A. Naturotherapy (Natural way of treatment for simple acne and prevention of severe acne).
1. Affected areas should be cleansed daily.
2. Change dietary habits avoid oily food, reduce intake of dairy products and sugar. Food should be rich in fibers and fruits.
3. Drink plenty of water.
4. Full sleep for 6-8 hours.
5. Pranayama (deep breathing exercises) helps to reduce stress and thus acne.
6. Avoid irritant cosmetic products.
Follow healthy lifestyle and health tips.

B. Pharmacotherapy
Consultation with a specialist may be necessary. Treatment should involve educating the patient and tailoring the plan to one that is realistic for the patient. Treatment failure can frequently be attributed to lack of adherence to the plan and also to lack of follow-up.

Topical therapy is useful in mild and moderate acne, as monotherapy, in combination and also as maintenance therapy. Systemic and physical therapy depends upon severity of acne.
1. Benzoyl peroxide – Mild acne usually managed with topical therapy. Initially started with low concentration topical benzoyl peroxide for short duration then gradually increased if tolerated.
2. Topical retinoids – Topical retinoids target the microcomedo–precursor lesion of acne. Tretinoin and isotretinoin are commonly used topical retinoids.
3. Topical antibiotics – Many topical antibiotics formulations are available, either alone or in combination. They inhibit the growth of P. acne and reduce inflammation. Topical antibiotics such as erythromycin and clindamycin are the most popular in the management of acne.
4. Other topical agents – Azelaic acid, Salicylic acid, Lactic acid/Lactate lotion, Tea tree oil 5%, Picolinic acid gel 10%, Dapsone gel 5% can also be used either single agent or in combination therapy.
5. Systemic antibiotics – Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. Gastrointestinal upset and vaginal candidiasis are most common side effects. Doxycycline can be associated with photosensitivity. Minocycline may produce pigment deposition in the skin, mucous membrane, and teeth. Autoimmune hepatitis, systemic lupus erythematosus-like syndrome, and serum sickness-like reactions occur rarely with minocycline.
6. Hormonal therapy – Used in female patients suffering with androgenic alopecia, hirsuitism, seborrhea, and proven ovarian or adrenal hyperandrogenism.
Oral contraceptives – Anti-acne effect of oral contraceptive governed by decreasing level of circulatory androgens through inhibition of luteinizing hormones (LH) and follicle stimulating hormone (FSH).
Spironolactone – functions primarily as a steroidal androgen receptor blocker.
Cyproterone acetate– it is first androgen receptor blocking agent used in combination with ethinyl estradiol to treat acne in females.
Flutamide – used to treat acne in females with hirsuitism.

7. Oral isotretinoin – used to treat modereate to severe acne which in not responsive to conventional therapy.

C. Physical treatment-
Intralesional injections of triamcinolone acetonide may be required for inflamed acne nodules or cysts, which can also be incised and drained, or excised under local anaesthetic.
UVB phototherapy or PDT can occasionally be used in patients with inflammatory acne who are unable to use conventional therapy.

Summary of treatment

• Comedones: Topical tretinoin
• Mild inflammatory acne: Topical antibiotics, benzoyl peroxide, or both
• Moderate acne: Oral antibiotics
• Severe acne: Oral isotretinoin
• Cystic acne: Intralesional triamcinolone
• Oral contraceptives are effective in treating inflammatory and noninflammatory acne in females.

Effective treatments aim to improve the condition and prevent worsening (including later scarring), and to restore emotional well-being and self-esteem. The psychological impact of acne must not be underestimated and should be considered in management decisions.

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), Indian Journal of Dermatology, http://www.merckmanuals.com, http://www.dermnetnz.org