Archive for July, 2009

Simple Tests In Constipation

The cause of severe constipation may be due to pelvic floor dysfunction. The pelvic floor dysfunction is suggested by the inability to evacuate the rectum completely, a feeling of persistent rectal fullness, rectal pain, the need to extract stool from the rectum digitally, application of pressure on the posterior wall of the vagina, support of the perineum during straining, and excessive straining at stool. The above symptoms should be differentiated from IBS (irritable bowel syndrome) where the sense of incomplete rectal evacuation is a common symptom.

Some simple tests to determine normal bowel evacuation:  

A simple clinical test in the doctor’s clinic can determine a nonrelaxing puborectalis muscle, which is by asking the patient strain to expel the index finger (of the doctor or examiner) during a digital rectal examination. Motion of the puborectalis posteriorly during straining indicates proper coordination of the pelvic floor muscles. Another test to determine if the evacuation of bowel is normal or not is done by placing a balloon-tipped urinary catheter inside rectum and inflated with 50 ml of water. Normally, a patient can expel it while seated on a toilet or in the lateral position; the weight needed to facilitate expulsion of the balloon is generally less than 200 ml (gram) of water, if the evacuation is normal.

Anorectal manometry if used in the evaluation of patients with severe constipation may find an excessively high resting (more than 80 mmHg) or squeeze anal sphincter tone, which suggests anal sphincter spasm, known as anismus. This manometry test can also identify a rare syndrome like adult Hirschsprung’s disease, by the absence of the recto-anal inhibitory reflex.

A formal psychiatric evaluation can be helpful sometimes. Simple psychiatric/psychological evaluation may identify certain psychological causes of constipation like eating disorders, control issues, depression, or post-trauma stress etc. These disorders may respond to cognitive or other intervention and may be important in restoring quality of life to patients who might present with chronic and severe constipation.

Balloon expulsion test is an important screening test for anorectal dysfunction. If the balloon expulsion test is positive, an anatomic evaluation of the rectum or anal sphincters and an assessment of pelvic floor relaxation are than used as tools for evaluating patients, especially in whom obstructed defecation is suspected.

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Posted by - July 25, 2009 at 11:56 am

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Popularity of Alternative Medicine

Alternative medicine (also known as CAM or complementary and alternative medicine) is any field of medical practice that is not proven by scientific study and experiment. Alternative medicine is the practice of medicine that does not fall in realm of conventional medicine. Some of the examples of alternative medicines are naturopathic medicine, ayurveda, meditation, yoga, unani, chiropractic medicine, traditional Chinese medicine, herbal medicine, homeopathy, acupuncture etc. and many more. Many of these alternative medicines are approved for practice in United States and many other countries and many are not permitted legally in many countries. In United States also some alternative medicine fields are permitted in some states, but not legal in other states. For example naturopathic medicine is permitted in at least 15 states of USA and District of Columbia and 5 provinces in Canada.

In many countries alternative medicine schools are being established for teaching various branches of alternative medicine. An alternative medicine school may be for naturopathy, homeopathy, ayurveda or some other field of alternative medicine. Alternative medicine (any of the fields of alternative medicine) is very popular in many countries including United States and alternative medicine schools are also gaining popularity among students. It is estimated that in US alone every year approximately $30 billion is spent on alternative medicine.  

Naturopathy is one of the popular branches of alternative medicine and naturopathic colleges are also being established in good numbers around the globe. In a naturopathic college, the common methods which are generally used are acupuncture, herbal medicine, colonic enema, chelation therapy, hair analysis, color therapy, homeopathy, iridology, public health and hygiene, nutrition, nature cure (therapies are based upon exposure to natural elements like sunlight, fresh air, exposure to cold or heat etc.), ozone therapy, traditional Chinese medicine, psychological counseling, physical medicine (exercise, hydrotherapy etc.), reflexology, rolfing etc. to name a few. Nutrition techniques which are used in naturopathy are pure vegetarianism, fasting, wholefood, abstinence from alcohol and sugar etc.   

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Posted by - July 24, 2009 at 12:20 pm

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Investigations in Severe Constipation

Very small percentage (less than 5%) of patients with constipation suffers from severe or intractable constipation. Most cases are seen by referral centers and by specialist doctors (generally gastroenterologists). Investigation of these patients suffering from severe intractable constipation may reveal certain things which were completely missed before like evacuation disorder, laxative abuse, malingering (patient do not have problem, but acting to have problem for personal benefit), psychological disorder etc.

In these patients with severe intractable constipation, evaluations of the function of the colon and pelvic floor as well as psychological status can help in the rational choice of treatment. But finding a cause even in tertiary referral center may be very difficult and only approximately two third patients are diagnosed with a valid cause of constipation.

 

Measurement of colonic function (transit):

For measurement of colonic transit radiopaque markers are used as they are safe, inexpensive, repeatable, reliable, and highly practicable in patients with constipation in clinical practice. Some simple methods are used, for example, radiopaque markers are ingested (by patient with severe constipation) and an abdominal flat film is taken 5 days later which generally indicate passage of 80% of the markers out of the colon without the use of laxatives or enemas. But this test does not provide any information about the transit profile of the stomach and small bowel.

Another test is also used sometimes, although it may be expensive and facility may not be available everywhere. The test is done with a delayed-release capsule, which contains radio labeled particles. This is a noninvasive technique which characterizes normal, accelerated, or delayed colonic function over 24 to 48 hours with low radiation exposure. This test can simultaneously assess gastric, small bowel and colonic transit. But the disadvantages of this test are very high cost and the need for specific materials, which can only be prepared in a nuclear medicine laboratory.

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Posted by - July 24, 2009 at 12:18 pm

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Specific Treatment of Indigestion

If the cause of indigestion can be identified, treatment of indigestion should be directed to correct the cause if possible. If the cause can not be identified, treatment has to be symptomatic and based on general principle of management.The common causes of indigestion are GERD (gastro-esophageal acid reflux disease) and functional dyspepsia (can not be treated satisfactorily unlike GERD).
 

Treatment of GERD:

Treatment of gastro-esophageal acid reflux disease should be started with PPI (proton pump inhibitor) drugs like omeprazole, pentoprazole, lansoprazole etc. PPIs are the first line and most effective drugs in treatment of GERD. Less potent but useful drugs are histamine H2 antagonists such as cimetidine, ranitidine, famotidine etc. and these drugs are generally used for treatment of mild to moderate GERD. If GERD is severe, proton pump inhibitors must be used and for very long duration. Patient can be put on histamine H2 antagonists such as cimetidine, ranitidine if treatment with PPI is giving good response. Combination therapy with a proton pump inhibitor and an H2 antagonist are not required but has been proposed for some refractory cases.

Eradication of H. pylori may also be required and helpful in many cases of indigestion as H. pylori is one of the causative factors of peptic ulcer and peptic ulcer is a common cause of indigestion. Many combination drugs are available for eradication of H. pylori. Most of the combinations include 10–14 days of a proton pump inhibitor with 2 antibiotics like metronidazole, clarithromycin and amoxicillin (any two of these three antibiotics). Eradication of H. pylori infection is associated with reduced prevalence of GERD, especially in the elderly patients.

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Posted by - July 24, 2009 at 12:11 am

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Weight Loss by Diet Pills

If you are obese or overweight, lowering your body weight to normal may be your goal, but you may not be able to do so. You might have tried many methods for reducing body weight, but failed to reduce body weight to normal or after reducing body weight to normal, you regained after some time. If you are in this category, you should get diet pills like orlistat or Alli (trade name) for reducing your body weight.

Orlistat is approved by FDA to be used for treatment of obesity. It is proved to reduce body weight in many clinical trials (hence approved by FDA for use) and can effectively reduce body weight in obese individuals. For getting the best result in weight loss alli or orlistat should be combined with regular exercise and a proper diet plan. Orlistat not only reduce body weight in obese individuals, it can also maintain (maintaining body weight after losing it is the main problem of weight reduction strategies) body weight after losing it.

How Alli act?

Alli or orlistat is an inhibitor of gastric and pancreatic lipase (the enzyme that is responsible for digestion and absorption fats from intestine). It reduces digestion and absorption of triglycerides by inhibiting lipase. It also reduces absorption fat soluble vitamins (vitamin A, D, E and K are fat soluble vitamins, which need fats for their absorption) and dietary cholesterol. By reducing fat absorption alli reduces body weight.

Side effects of orlistat:

Alli has some side effects which are commonly experienced by persons using it for weight loss. The side effects may be common, but they are generally mild and not serious. The side effects of alli are nausea, pain in abdomen, flatulence (gas in stomach), fatty diarrhea etc. These side effects usually go away after using it for sometime and it is not difficult to adjust to these side effects.     

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Posted by - July 23, 2009 at 11:29 am

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Principles of Treatment of Indigestion

Some general principles of treatment of indigestion should be followed. For example if the cause (e.g. GERD, lactase deficiency, biliary colic etc.) of indigestion can be identified, the therapy should be directed towards the cause of indigestion. If the cause can not be identified, than treatment should be directed towards symptomatic relief of the patient for improving patients’ health.

General principle of treatment of indigestion:

For mild indigestion, reassurance may be the only intervention needed, (especially mentioning the patient of indigestion that a careful evaluation revealed no serious organic disease). Medicines that can cause acid reflux or dyspepsia should be avoided and stopped (if already using) if possible. Patients with GERD (gastro-esophageal reflux disease) should limit alcohol, caffeine, chocolate, and tobacco use because of the effects of these substances on the LES (lower esophageal sphincter) is usually relaxing, which causes easy acid reflux to esophagus. Other measures like consumption of a low-fat diet, avoiding snacks before bedtime, and elevating the head of the bed should be taken as general measure.

Specific therapies for organic disease (if present) should be offered when possible and if the disease can be identified. Examples of specific therapies are surgery, which is appropriate in disorders like biliary colic, while diet changes are indicated for lactase deficiency or celiac disease. Some illnesses such as peptic ulcer disease may be cured by specific medical regimens. However, as most indigestion is caused by GERD or functional dyspepsia, medications that reduce gastric acid, stimulate motility, or blunt gastric sensitivity are indicated.

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Posted by - July 23, 2009 at 11:27 am

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Treatment of Constipation

Constipation is persistent, difficult, infrequent, or seemingly incomplete defecation. It is very difficult to define constipation precisely due to the wide range of normal bowel habits. For treatment of constipation, the cause of constipation should be identified. Treatment of constipation is based on the cause of it.

Patients with slow-transit constipation are treated with laxatives. The examples of laxatives are bulk, osmotic, prokinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of magnesia, lactulose, polyethylene glycol (colonic lavage solution), lubiprostone, and bisacodyl. There is also newer treatment modality aiming at enhancing motility and secretion and may have application in special circumstances such as constipation-predominant IBS (irritable bowel syndrome) in females or in severe constipation.

If a 3 to 6 months trial of medical therapy fails with above treatment regimes and patients continues to have documented slow-transit constipation which is not associated with obstructed defecation, the patients should be considered for laparoscopic colectomy (resection or part of colon) with ileorectostomy (joining of ileum and rectum surgically).  But these operations should not be done if there is continued evidence of an evacuation disorder or a generalized GI dysmotility. Referral to a specialized center for further tests of colonic motor function should be done in these cases.

The presence of megacolon and megarectum is indication for surgical intervention in constipation. But there may be unacceptable complications after surgery like small-bowel obstruction and fecal soiling, particularly at night during the first postoperative year. Frequency of defecation is 3–8 per day during the first year and 1–3 per day from the second postoperative year onwards.

Patients with severe slow-transit constipation require aggressive medical or surgical treatment. However, approximately only 60% of patients with severe constipation are found to have such a physiologic disorder (colonic transit delay and evacuation disorder). Patients with spinal cord injuries or other neurological disorders require a bowel regime that includes rectal stimulation, enema therapy, and carefully timed laxative therapy. 

Patients with evacuation and transit/motility disorder should pursue pelvic floor retraining (biofeedback and muscle relaxation), psychological counseling, and dietary modification first, and than colectomy and ileorectosomy (if colonic transit studies do not normalize and symptoms are intractable despite biofeedback and optimum medical therapy). If patient only has pelvic floor dysfunction, biofeedback training has a 70–80% success rate which is measured by regaining of comfortable stool habits.

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Posted by - July 21, 2009 at 11:55 pm

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Anabolic steroids in sports

Anabolic steroids (also can be called anabolic-androgenic steroids) are synthetic testosterone (which is the male hormone). They are a class of drugs that are legally available only by prescription and are prescribed to treat a variety of conditions that cause a loss of lean muscle mass. In treatment of lean muscle mass the anabolic steroids are very effective and popular drugs.

Information is available on legal steroids manufacturers in the internet. There are also useful prohormones available in the internet which can help building body for a bodybuilder quickly and with minimal side effects of steroids. Instead of using anabolic steroids, the use of these highly effective prohormones with minimal side effects should be encouraged.  

The illegal use of steroids (mainly anabolic steroids like Nandrolone, Oxandrolone, Stanozolol etc.) is prevalent in the field of professional sports despite strict control measures and banning of substances like anabolic steroids and other performance enhancing drugs in sports by sports governing authorities. Many athletes and other sports persons are using these performance enhancing substances despite the ban and possible punishment if caught using them by IADA (International Anti Doping Agency) which is approved by all sports governing bodies and Governments. The use of steroids and other performance enhancing substances are used because anyone can buy steroids and other performance enhancing substances anytime very easily.

The use of anabolic steroids and other performance enhancing substances should be stopped by sportspersons. Sportspersons should be educated about the ill effects of these substances have on general health and well being of an individual and also the immoral aspect of unfair means in sports competitions, which are supposed to be symbol of peace and universal brotherhood.

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Posted by - July 21, 2009 at 3:55 pm

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Treatment of Chronic Diarrhea

If diarrhea continues for more than 4 weeks, it is considered as chronic diarrhea. Chronic diarrhea requires evaluation to rule out underlying pathology. Compared to causes of acute diarrhea, most of the causes of chronic diarrhea are noninfectious.

Principle of treatment of chronic diarrhea:

Treatment of chronic diarrhea depends on the specific cause of diarrhea and it is directed towards the cause of diarrhea, which may be curative, suppressive, or empirical. If the cause can be removed or eradicated, the treatment of chronic diarrhea is curative as with resection of a colorectal cancer, antibiotic administration for Whipple’s disease, or discontinuation of a drug (if any drug is the cause of chronic diarrhea).

For many chronic conditions, diarrhea can be controlled by suppression of the underlying mechanism which is causing the chronic diarrhea. Examples are elimination of dietary lactose for lactase deficiency or gluten (gluten free diet) for celiac sprue, use of glucocorticoids or other anti-inflammatory agents for idiopathic IBDs (inflammatory bowel diseases), adsorptive agents such as cholestyramine for ileal bile acid malabsorption etc. Other examples are use of proton pump inhibitors such as omeprazole for the gastric hypersecretion of gastrinomas, somatostatin analogues such as octreotide for malignant carcinoid syndrome, prostaglandin inhibitors such as indomethacin for medullary carcinoma of the thyroid, and pancreatic enzyme replacement if there is any pancreatic insufficiency.

But if the specific cause or mechanism of chronic diarrhea can not be pinpointed, empirical therapy may be beneficial. For example loperamide, is often helpful in mild or moderate watery diarrhea. For those with more severe diarrhea, codeine or tincture of opium may be beneficial. Such antimotility agents should be avoided with IBD, as there may be precipitation of toxic megacolon. Clonidine, an alpha-2 adrenergic agonist, may allow control of diabetic diarrhea.

General measures:

Fluid and electrolyte replacement is an important and essential component of management for all cases of chronic diarrhea. Replacement of fat-soluble vitamins may also be necessary in patients with chronic steatorrhea (lipids can not be absorbed or fat malabsorption).

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Posted by - July 19, 2009 at 9:34 am

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Steroid Abuse

Steroids are generally of two types, the first type is anabolic steroids and the second type is corticosteroids. The corticosteroids group of steroids are commonly used in treatment of bronchial asthma and anabolic steroids are medically (they are also most commonly misused or abused steroids) used for treatment of generalized weakness and to treat lean body muscle mass. Corticosteroids are drugs that doctors often prescribe to help control inflammation in the body (asthma is also due to chronic inflammation and that is why corticosteroids are very useful in treatment of asthma). Steroids are among the commonly abused drugs. They are abused in the field of sports also and most commonly abused drugs in sports. Some of the commonly abuse anabolic steroids are Clenbuterol, Oxandrolone, Nandrolone etc.

The abuse of steroids has serious and potentially fatal side effects. These side effects of steroids are very common among abusers, because they take these substances continuously and for prolonged period as well as at very high doses. Sometimes abusers may take as high as 10 to 100 times higher than recommended dose for medical use of the drugs. The use of higher dose and for prolonged period makes the side effects very common and some are with serious consequences including death of the abuser.

Some of the serious (and very common among abusers) side effects are infertility, heart attack, incidence of cancer, hepatitis, shrinking of testes etc. There are also many common side effects, although they are not as serious.  

The introduction of internet has made it easy to buy Clenbuterol and other medicines (for use as well as for abuse and addiction), while sitting at home.

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Posted by - July 18, 2009 at 1:48 am

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