Disease Treatment

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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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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Treatment of Acute Diarrhea

Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency and with a typical Western diet stool weight of more than 200 grams can be considered as diarrhea. 

Principle of treatment of acute diarrhea:

In acute diarrhea the most important part of treatment is the replacement of lost fluid and electrolytes. Fluid replacement should be gradual and over a period of time. In mild cases of acute diarrhea fluid replacement is all that may be required. Oral sugar-electrolyte solutions used in sports as drinks or designed formulations should be started promptly with severe diarrhea to limit dehydration, as severe ehydration is the major cause of death in severe diarrhea. If dehydration is very severe, especially infants and the elderly, require IV (intravenous) re-hydration for maintaining patients’ health.

If the dehydration is moderate as seen in non-febrile and non-bloody diarrhea, anti-motility and anti-secretory agents such as loperamide can be used. But drugs like loperamide should be avoided if the diarrhea patient is suffering from febrile dysentery, which may cause prolongation of diarrhea.

Role of antibiotics in acute diarrhea:

Use of antibiotics may sometimes reduce the severity and duration of diarrhea in some selected cases. Ciprofloxacin (500 mg twice a day for 3 to 5 days) is used by many doctors’ for treatment of severely ill patients with febrile dysentery empirically without diagnostic evaluation. If the cause of diarrhea is suspected to be due to giardiasis, metronidazole (250 mg 4 times a day for 7 days) can be used successfully. Antibiotic coverage has to be given whether or not a causative organism is discovered in patients who are immune deficient, have mechanical heart valves or recent vascular grafts, or are elderly.

Antibiotic prophylaxis should be given for certain patients traveling to high-risk countries in whom the likelihood or seriousness of acquired diarrhea would be especially high, including those with immunocompromise, IBD (inflammatory bowel disease e.g. ulcerative colitis), hemochromatosis, or gastric achlorhydria (absence of acid in stomach). For prophylaxis the use of trimethoprim/sulfamethoxazole (Bactrim), ciprofloxacin, or rifaximin (rifaximin not be suitable for invasive disease) may reduce bacterial diarrhea in such travelers by 90%. Finally, physicians should be vigilant to identify if an outbreak of diarrheal illness is occurring and to alert the public health authorities promptly, which may reduce the ultimate size of the diarrhea affected population.  

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Posted by - July 17, 2009 at 11:44 am

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Treatment of Cellulitis

Cellulitis is an acute inflammatory condition of the skin that is characterized by localized pain, redness, swelling, and rise in temperature of that particular area of inflammation. The commonest organisms that cause cellulitis are staphylococcus and streptococcus and they being the commonest organism, the treatment is generally targeted at killing these organisms.

The primary treatment (first line treatment) of cellulitis:

The first line treatment of cellulitis is with newer penicillin. Among newer penicillins Nafcillin or oxacillin at the dose of 2 gram intravenously every 4 to 8 hourly is the drug of choice.

Second line treatment of cellulitis:

Second line treatment of cellulitis is with cephalosporins, other semi-synthetic penicillins or with drugs like erythromycin. Among cephalosporins the drug of choice is Cefazolin, (dose 1 to 2 gram every 8 hourly). Ampicillin + sulbactam (semisynthetic penicillin) or Erythromycin, 0.5 to 1.0 gram intravenously every 6 hourly or Clindamycin, 600–900 mg intravenously every 8 hourly can also be used as second line drug for treatment of cellulitis.

The resistance to antibiotics like erythromycin is a problem in treatment of infections like cellulitis. The frequency of erythromycin resistance in group A Streptococcus is very common and currently approximately 5% in the United States but has reached as high as 70% to 100% in many countries. Most (though not all), erythromycin-resistant group A streptococci are susceptible to clindamycin. Approximately 90% to 95% of Staphylococcus aureus (which also cause cellulitis) strains are sensitive to clindamycin.

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Posted by - June 28, 2009 at 12:20 am

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Treatment of Folliculitis

Folliculitis is infection and inflammation of hair follicles. Hair follicles are present all over the body except palms and soles. So practically Folliculitis can occur anywhere in the body except palms and soles. Hair follicles are portals of large number of bacteria.

Causative organisms of Folliculitis:

The commonest organism of Folliculitis is Staphylococcus aureus and it usually causes localized folliculitis. Other causative organisms are Pseudomonas aeruginosa, Propionibacterium acnes (causative organism of acne or pimples), Schistosoma species etc.

Diffuse folliculitis can occur in two settings, “hot-tub” folliculitis and “swimmer’s itch”. Hot-tub folliculitis occurs when waters is insufficiently chlorinated and maintained at temperatures of 37–40°C and the infection is generally self limiting (although bacteremia and shock may occur rarely). The causative agent in hot-tub folliculitis is Pseudomonas aeruginosa.Swimmer’s itch occurs when a skin surface is exposed to water infested with freshwater avian schistosomes (Schistosoma species). Free-swimming schistosomes can readily penetrate human hair follicles but quickly die and elicit a brisk allergic reaction which cause intense itching and erythema.

Sebaceous glands empty into hair follicles and ducts and if they are blocked they form sebaceous cysts, which may resemble staphylococcal abscesses. Chronic folliculitis is uncommon except in acne vulgaris (a form of folliculitis), which is generally caused by normal flora Propionibacterium acnes.

Treatment of folliculitis:

If the organisms are sensitive to beta-lactum antibiotics, they should be used first. Examples of beta-lactum antibiotics are penicillins (older and newer synthetic penicillin like amoxycillin), cephalosporins (like Cefazolin) etc. If the organisms are not sensitive to beta-lactum antibiotics, vancomycin (1 gm intravenously every 12 hourly) or linezolid (600 mg intravenously every 12 hourly) should be used. Sometimes tetracycline and trimethoprim-sulfamethoxazole can also be used.     

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Posted by - June 10, 2009 at 1:05 am

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Management of peptic ulcer

The aim of treatment:

The main aim of treatment of peptic ulcer is to provide symptomatic relief to the patient in the short term, induce ulcer healing and to prevent relapse in the long run. If H. pylori are found, attempt should be made to eradicate with appropriate antibiotic therapy

General measures:

 General measures for management of peptic ulcer are avoidance of smoking as it has a causative role in peptic ulcer and also smoking cause delay in ulcer healing. So smoking should be strongly discouraged. Aspirin and other NSAIDs (non-steroidal anti inflammatory drugs) should be avoided as far as possible because of the injurious effect they have on gastric and duodenal mucosa. If NSAIDs are required for pain relief of some other pain like toothache, a selective COX2-inhibitor NSAID (e.g. valdecoxib, celecoxib etc.) should be given or they can be given with proton pump inhibitor drugs (e.g. omeprazole, pantoprazole etc.) or with prostaglandin analogues like misoprostol. Alcohol should be avoided (although alcohol in moderation does no harm) as well as excess tea and coffee.

Medical Management:

Short term management of peptic ulcer is done with H2-receptor antagonist (e.g. ranitidine, famotidine etc.), proton pump inhibitor drugs (e.g. omeprazole, pantoprazole, rabeprazole, etc.), sucralfate, and prostaglandin analogues (e.g. misoprostol) or with antacids. All the above mentioned medications are equally effective in treatment of peptic ulcer.

Maintenance therapy is done with proton pump inhibitor drugs (e.g. omeprazole) or with H2-receptor antagonist like ranitidine (either of the group of drugs is safe and effective in long term maintenance).

Eradication of H. pylori is important if found in biopsy. For eradication of H. pylori 14 day treatment is given with omeprazole 20 mg, metronidazole (or tinidazole) 400 mg and clarithromycine 250 mg (available as kit which contains all 3 medicines). One kit is to be taken 2 times a day for 14 days. Other combination kits are also available where clarithromycine is replaced with amoxicillin 750 mg.

Surgical treatment:

If none of the above mentioned treatment regimens including eradication of H. pylori fails, surgical treatment should be considered. Indication of surgical intervention is strengthened by the younger age of the patient, complications like hemorrhage or perforation of intestine, strong family history of peptic ulcer, frequent relapses, if ulcer is causing obstruction to gastric outflow or produced an hour glass stomach due to fibrosis. There are also patients who do not comply with prolonged medical management, can be treated with elective surgical intervention. But in case of elderly patients surgical operation should be avoided.

Finally every ulcer should be viewed with seriousness, especially long standing gastric ulcer as it can turn malignant although rarely. As peptic ulcer is a common problem in the modern life, it should be appropriately treated and doctor’s advice followed strictly.   

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Posted by - May 21, 2009 at 12:59 am

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Drug Addiction Treatment

Drug addiction being an international problem which does not spare any nation should be adequately addressed and treated. For a successful drug addiction treatment the best approach is a holistic approach, which covers not only the medical and psychological aspects of the drug addict, but also covers the emotional and spiritual needs of the addict. For successful drug treatment or drug addiction treatment the role of psychiatrist is the most important as well as psychological counseling.  

The drug treatment of the addicts is not an easy task, as the addicts are usually not interested in getting good treatment and lead a drug free life. Many addicts can not even imagine a drug free life and to treat these drug addicts it is a gigantic task, which need coordinated approach of professional doctors, other technical staffs, supporting staffs, family members (of the addict) and friends of the drug addicts. The govt. help in addressing the social evil of drug addiction is very important. The help of former drug addicts is also very important to motivate the addicts and should be sought. Drug addiction is basically a social problem but the first step of management of the problem of drug addiction, is a medical management.

The drug addiction treatment is not complete without the drug rehabilitation. For drug rehabilitation, after successful drug treatment the govt., social workers play the most important role. Without good drug rehabilitation the rate of relapse of drug addiction (after successful treatment of drug addiction) may be very high. To reduce the relapse rate of drug addiction social activists and the govt. should play a major role with cooperation from the drug treatment centers.

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Posted by - May 18, 2009 at 11:41 am

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Treatment of Premenstrual Tension

Premenstrual tension is as the name suggests certain symptoms (symptoms include headache, gastro-intestinal upset, irritability, lethargy, constipation, frequency of urination, fullness of breasts and some women experience eruption of acne or pimples) few days preceding menstruation. Treatment of premenstrual tension depends on elimination of extra-cellular fluid by a salt free diet and also by limiting water intake for about 10 days preceding menstruation. The treatment regimens used are:

  1. Use of diuretics like chlorthiazide 250 mg single dose or saline purgatives for 10-12 days starting at the onset of the premenstrual symptoms until menstruation starts is very successful.
  2. Use of methyl testosterone 10 mg daily in the last half of the menstrual cycle in certain cases of premenstrual tension and use of large dose of progesterone is useful. But use of progesterone and testosterone can not be explained scientifically because if the theory of water retention as causative factor for premenstrual tension is accepted, than progesterone and testosterone are contra-indicated. 
  3. For treatment symptoms like breast fullness or congestion adequate breast support and fluid restriction and elimination is required. For treating the premenstrual headache (migraine like) ergotamine tartrate in large dose of maximum 10 mg daily and care should be taken so that the dose does not exceed 10 mg per day otherwise there is danger of serious side effects like peripheral vascular spasm (which is seen with all alkaloid drugs).
  4. Many women with premenstrual tension suffer from acne on the body and face and also some skin eruption. Unfortunately the treatment of these conditions is unsatisfactory.

The most important factor in premenstrual tension is psychosomatic and it commonly affects women who are highly strung, introspective and neurotic. The headache or breast tenderness is exaggerated into an obsession of serious nervous disease or the woman becomes that she is having cancer. Due to all these the woman becomes short tempered and her family life and social life get disturbed. There may be tendency to suicide due to extreme depression. Study reveals that the female crime is higher during premenstrual phase of the period. These patients should be treated with patience and reassurance. Psychiatric consultation should be advised for these patients. 

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Posted by - April 20, 2009 at 4:12 pm

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Treatment of Spasmodic Dysmenorrhea

Treatment of spasmodic dysmenorrhea can be following:

  • Explanation of physiology of menstruation, education and reassurance to the patient are important aspects of management of spasmodic dysmenorrhea.
  • Proper nutrition with balanced nutritious diet, regular physical activity (spasmodic dysmenorrhea is more common among women with sedentary lifestyle), and proper treatment of constipation and adaptation of healthy lifestyle are very much essential in the treatment of spasmodic dysmenorrhea.
  • Initially spasmodic dysmenorrhea should be treated with simple analgesics (pain killers) like aspirin, paracetamol and codeine. Antispasmodics with atropine derivatives, Buscopan (hyoscine bromide), Baralgan etc. are also helpful. With any of the above a tranquillizer is beneficial.
  • Prostaglandin synthetase (inhibit the actions of prostaglandins) inhibitors are successful in the treatment of spasmodic dysmenorrhea. Prostaglandin synthetase inhibitors reduce the activity of myometrium of uterus and reduce pain. The drugs are mefanamic acid (500 mg daily), flufenamic acid (200 mg daily), indomethacin (50 mg daily), and naproxen sodium (200 mg daily) etc. The side effects of these drugs are headache, GIT manifestations like vomiting, reduced menstruation, blurring of vision, acute renal problem etc. due to prolonged use.
  • Endocrine treatment: oral contraceptive (steroids) pills can be of very good use in treatment of dysmenorrhea especially women who want contraception. The cure rate is very good, but the biggest disadvantage is the need of taking contraceptive pills for 21 days for the pain of few days (2 to 3 days) besides side effects and contraindications of oral pills.
  • Danazol a drug which suppress hypothalamic-pituitary-ovarian axis is sometimes helpful in treatment of dysmenorrhea.
  • Surgical dilatation of cervix is also useful in treatment of dysmenorrhea. But the relief may be temporary and excessive and forcible dilatation may lead to complications like premature labor, habitual abortion due to cervical incompetence in subsequent pregnancies. This is therefore not recommended.
  • Presacral sympathectomy is a surgical procedure that is reserved for patients for whom all other measures have failed. But this surgery does not guarantee benefits.
  • Hysterectomy is reserved for the cases for patients there is also pathology pelvis like fibroids and those who have completed their family and do not want any more children.

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Posted by - April 2, 2009 at 12:57 am

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Breast Cancer: Surgical Treatment

The main treatment of breast cancer is surgical treatment. Surgery is the mainstay of primary breast cancer in all cases. There are many forms of surgery which are done for treatment of breast cancer. Radical mastectomy or modified radical mastectomy is removal of the breast along with the breast tumor and the normal tissue. But these days’ breast-conserving surgeries are preferred.

Breast-conserving treatments (or surgery), consisting of the removal of the primary tumor by lumpectomy (removal of lump or the tumor) with or without giving radiotherapy to the breast. The survival after breast-conserving treatments is as good as that of radical mastectomy or modified radical mastectomy (or some times give better result) with or without radiotherapy. If radiotherapy is given after breast-conserving surgery the chances of recurrence of breast cancer is greatly reduced. But there is always a possibility of recurrence after breast-conserving treatment but the overall 10 year survival rate is at least as good as that after more radical surgery. Postoperative radiation therapy to regional nodes following mastectomy (Radical mastectomy or modified radical mastectomy or breast-conserving surgery) is also associated with an improvement in survival. Since radiotherapy can reduce the rate of local or regional recurrence, it is strongly recommended following mastectomy for women with high-risk primary tumors.

At present, nearly one third of women in the United States are managed by lumpectomy (breast-conserving surgery). Breast-conserving surgery is not suitable for all patients. It is not suitable for tumors more than 5 cm (or for smaller tumors if the breast is small), for tumors involving the nipple and areola complex; for tumors with extensive intraductal disease involving multiple quadrants of the breast, for women with a history of collagen-vascular disease. It is also not suitable for women who do not have the motivation for breast conservation or who do not have access to radiotherapy. But the group who are not suitable for breast-conserving treatments do not constitute as the number of radical (mastectomy) treatment done. So many women still undergo mastectomy, who could safely avoid this procedure and probably would if appropriately counseled.

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Posted by - March 29, 2009 at 12:06 pm

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