Gallstones: To Operate or Not?
Discussant: Billy James G. Uy, M.D.
allbladder is a small pouch-like organ underneath the liver. It stores and concentrates bile, a liquid produced to help digest and absorb fat, so it’s rich in cholesterol. Gallstones (cholelithiasis) are small stones made of bile acid pigments formed in the gallbladder. When there is sudden intense abdominal pain caused by trapped gallstone in the opening of the gallbladder, the condition is called “Biliary colic”. On the other hand, Cholecystitis refers to the inflammation or swelling of the gallbladder.
Some risk factors in the production of gallstones are: (1) gender, specifically for female women above 40 years old; pregnancy and taking oral contraceptive pills (or high estrogen therapy) also increases risk, (2) overweight individuals who are on a rapid weight loss diet, or had undergone bariatric surgery also increases risk, and lastly (3) genetic or if it is in the family history.
The symptoms and diagnosis include:
• High fever with or without chills
• Biliary colic (intermittent pain after eating)
• Yellowing of the eye or skin
• Intense abdominal pain in right upper side lasting for longer than 4-8 hours
And gallstones can be determined by the following examinations:
• CT / MRI scan
• Blood test
• HIDA (Hepatobiliary) scan
There are three approaches in the treatment of gallstones namely, Asymptomatic, Symptomatic, and Alternative. Asymptomatic (showing no pain or symptom) involves close monitoring. Prophylactic cholecystectomy (surgery) is needed under the following circumstances: cirrhosis (scarring of the liver), diabetes, portal hypertension (high blood pressure in the liver), and impaired immunity like post-transplant patients.
On the other hand, Symptomatic (or involving pain) can be dealt by using painkillers, antibiotics, bowel rest, and surgery if all else fail. Sometimes Laparoscopic cholecystectomy is done, which is around a few centimeter cuts made on the abdomen. Others may opt to do Open cholecystectomy or skin incision under the right ribs which is just as effective as laparoscopic cholecystectomy, but have a longer recovery time and more scarring.
Lastly, Alternative treatments involve Ursodeoxycholic acid, which is the only medically recognized drug to dissolve small non-calcified gallstones. It is taken usually for up to two years, but gallstones can still recur after treatment. Therefore, maintaining a low cholesterol diet is needed.
Doctors recognize the following complications:
• Acute cholecystitis (inflammation of the gallbladder): can lead to gallbladder abscess or even rupture.
• Acute pancreatitis (“Bangungot”): inflammation or swelling of pancreas. It can cause severe pain and death if untreated.
• Acute Cholangitis (infection of the bile duct): can lead to high fever, jaundice, chills, itchy skin, confusion or mental deterioration and even death.
• Cancer of the gallbladder: most serious but RARE complication of gallstone. (less than 0.001% incidence)
• Gallstone ileus: bowel obstruction due to big gallstone
• Jaundice (yellowing of the skin and eyes)
Prevention is always better than cure. To prevent gallstones, the following diet is recommended: avoidance of fatty foods, low fat, high fiber diet, and cutting down on alcohol consumption. It is also recommended to lose weight, but avoid low calorie and rapid weight-loss diets.
n MEDICAL FORUM NO. 254
Goiter: Myths and Fallacies
Discussant: Susan Yu-Gan, M.D.
he Thyroid gland is a butterfly shaped organ at the base of the neck. It is responsible in producing tetraiodothyronine (T3) and thyroxin (T4), which are used for a lot of our bodily functions like memory, heart rate, body metabolism, intestinal movement and even ovulation. The condition wherein there is enlargement of the thyroid gland is called Goiter.
There are 2 kinds of enlargement (1) Diffuse or “simple goiter” is often due to iodine deficiency, while (2) Nodular, which can be benign or malignant. Here are some myths and fallacies regarding the development of goiter:
• Straining or bearing down during labor can cause goiter.
False. Pregnancy itself does not trigger goiter. During pregnancy TSH levels raise, thus causing enlargement of the thyroid gland.
• Eating cabbage, carrots and cassava can cause goiter.
False. These foods are considered goitrogens, but you need to eat truckloads of these foods to cause goiter.
• When a person has goiter, he should eat lots of seafood.
False. Not all goiters are due to iodine deficiency. Some terminologies, Hyperthyroidism is due to too much thyroid hormones. So, eating too much seafood may aggravate the condition. On the other hand, Hypothyroidism is due to the lack of thyroid hormone, most commonly due to destruction of the thyroid gland (from radioactive iodine therapy, thyroid surgery or hashimoto’s thyroiditis). So, giving more iodine will not help in any way.
• Seafood are the only source of iodine.
False. There are other sources of iodine like milk and dairy products, bread and other bakery products, iodized salt and even water.
• Once salt is iodized, it is good forever.
False. Iodized salt should be consumed within 6 months.
• Iodized salt can cure iodine deficiency.
False. Hypothyroidism (Cretinism) is an iodine deficiency condition of the baby developed during mother’s pregnancy. This cannot be cured by iodine treatment and caused by lack of iodine during pregnancy. It can be diagnosed by newborn screening. Babies can be treated by partially giving thyroxin. The suggested iodine intake is 250 mcg for pregnant women, around 290 mcg for lactating women, and 150 mcg for a normal person.
• Too much iodine is harmful.
False. Long term consumption of iodine is not toxic. Excess iodine taken in is excreted by the body through urine.
n MEDICAL FORUM NO. 255
Recognition and Management of Obstructive Sleep Apnea
Discussant: Jonalyn Chris T. Ang, M.D.
leep-disordered breathing (SDB) is signified by snoring of varying degrees of intensity, which exists along a continuum of severity. It is the severe obstructive sleep apnea with profound hypoxemia and sleep disturbance. On the other hand, Obstructive Sleep Apnea (OSA) is a sleep disorder involving disruption of normal breathing during sleep.
Risk factors for these sleeping disorders are: obesity, aging, and craniofacial dysmorphism (skull deformity). The symptoms include, during daytime: excessive sleepiness, afternoon drowsiness, forgetfulness, impaired concentration and attention, personality changes, and morning headaches.
During night time, snoring, snorting, observed apneas, awakening with a sensation of choking or gasping, unexplained tachycardia, restless sleep, sweating during sleep, nocturia (need to wake and pass urine at night one or more times), bruxism (the involuntary or habitual grinding of the teeth, typically during sleep), and nocturnal gastroesophageal reflux or acid reflux.
The diagnosis requires clinical evaluation and overnight sleep. Polysomnography (PSG) or sleep study is the gold standard to determine the presence of apnea or hypopnea. Some definitions,
• Obstructive apnea—the complete or near-complete cessation of airflow for a minimum of 10 seconds.
• Obstructive hypopnea—partial cessation of airflow for a minimum of 10 seconds followed by 4% desaturations or arousals.
• Apnea–Hypopnea Index (AHI): number of abnormal breathing events during nocturnal sleep (number of apneas plus hypopneas per hour of sleep)
• Respiratory Disturbance Index (RDI): number of apneas plus hypopneas plus respiratory effort–related arousals (RERAs) per hour of sleep
As for the treatment, the continuous positive airway pressure (CPAP) is the first choice for obstructive sleep apnea–hypopnea syndrome. The effectiveness is at an appropriately set pressure this treatment is almost always effective. Some limitations would be the patient’s acceptance and tolerance of treatment.
Oral appliances and surgery for obstructive sleep apnea (OSA) may also be done, but a variety of medical therapies may be useful adjunct to positive airway pressure therapy in selected cases. A natural way would be considering weight loss. It can also be the result of dietary manipulation or surgery that can partially ameliorate or even reverse OSA.
Another treatment is Supplemental Oxygen Therapy for severe hypoxemia in OSA that cannot be achieved by interventions that are primarily directed at maintaining upper airway patency. This can be done also to improve alertness when daytime sleepiness persists despite the successful amelioration of apneas and hypopneas with positive pressure therapy. Some drugs would be amphetamines and methylphenidate which have common side effects and can lead to dependence. Modafinil or armodafinil are safer choices but not locally available.
Contraindications of these drugs are Methylxanthines, progestational agents, selective serotonin reuptake inhibitors, and mixed serotonin receptor antagonists: no substantial and consistent results for routine treatment of OSA. Alcohol and sedatives can also worsen OSA symptoms, patients should refrain from these agents close to bedtime.
n MEDICAL FORUM NO. 257
The Management of
Urinary Stone Disease
Discussant: Johnson L. Sy, M.D.
rinary Stone can be found in different locations in the urinary system. About 45.9% of the time, it can be found in the kidney, in the Ureter (29.7%), Urinary bladder (23%), and Urethra (1.4%). The process of stone formation have the following steps: supersaturation, crystallization, nucleation or aggregation and retention. Some internal factors which contribute to the stone formation are, blood, anatomy of urine passageway, kidney, and urine.
On the other hand, environmental factors include drinking water (example, source of tropical country like Philippines has high mineral content). The causes of urinary stones include, UTI (Urinary Tract Infection), dehydration, metabolic disorders, hereditary disorders or family history, and sedentary lifestyle or immobilization. Excesses of the following in the diet can also bring about urinary stones: Calcium, Vitamin D, Vitamin C, Purines, Oxalates, and Urine pH.
Some factors to be considered for the treatment: stone size and location, degree of obstruction, severity of symptoms, infection or urosepsis, and renal function: solitary kidney or azotemia. Medical treatment includes:
• Urinary antiseptic or prophylaxis: Nitrofurantoin • Herbal: cogon, lemon grass, corn hair, Orthosiphon
• Alkalinize urine pH: Sodium bicarbonate
• Increase urinary citrate: Potassium citrate
• Diuretic and/or stone dissolution: Blumea balsamifera
• Muscle relaxants or anti-inflammatory agents: Terpenes
• Anti-spasmodic agents: Hyoscine N-butylbromide, Tiropamide
• Increase ureteral hydrostatic pressure or relaxes ureterovesical opening: Tamsulosin
• Alkalinize urine pH and Increase urinary citrate: Sodium citrate and sodium bicarbonate
As for surgery, it is skipped when the kidney stone is less than 1 cm and instead, Extracorporeal Shockwave Lithotripsy (ESWL) procedure is done.
Staghorn calculi, or Open surgery is done when the kidney stone is more than 2 cm. For lower pole, obesity, Percutaneous Nephrostolithotripsy (PCNL) or with ESWL is considered.
For Ureteral stone, ESWL is done for proximal third, or less than 1 cm. For larger stones Laparoscopy or Open Surgery would be the preferred procedure. For middle to distal third, ureterovesical junction (UVJ): Ureteroscopy (URS) with laser or basket is the preferred option.
For Urethral stones, a “push back” technique with sounds or scope can also be done. On the other hand for Bladder stones, Cystolitholapaxy, Holmium Laser Cystolithotripsy, Open Surgery are considered. Some other options are Retrograde Intrarenal Surgery (RIRS), Ultrasonic or Holmium Laser Lithotripsy, Minimally invasive surgery (MIS): Laparoscopic Ureterolithotomy, Pelveolithotomy, PCNL, mini-PCNL, and ultra mini-PCNL.
For follow-up surveillance and monitoring, the following dietary modification is recommended:
• Vitamin C supplement: less than 1 gram/day
• Sodium: 3 grams/day
• Fluid intake: at least 8 glasses or 2 liters/day
• Avoid purine excess: less than 500 mg./day
• Avoid nuts, spinach, tea, chocolate, alcohol beverages
• Increase citrus fruit intake: dalanghita, grapefruit, lemon, kalamansi
• Calcium intake: 1,200 mg./day (1 glass milk and 1 tablet of calcium plus Vitamin D)
Imaging may also be required for monitoring, specifically by the use of Ultrasound. For laboratory tests, the following are checked: Urine pH, 24 hour urinary calcium, 24 hour urinary citrate, GFR, serum creatinine, and urinalysis.
n MEDICAL FORUM NO. 258
Managing Patients with
Discussant: Dante G. Ang, M.D.
epatocellular Cancer (HCC) or primary liver cancer is one of the common cancers in Asia. Around 85% of HCC originates from cirrhotic liver. Causes of Liver Cirrhosis include Hepatitis B (most common cause), excessive alcohol intake, diabetes mellitus, and viral Hepatitis C.
As for the treatment, liver transplantation is the current best option for early HCC, as the procedure can remove cancer cell in the cirrhotic liver. A limitation would be lack of available liver donor, and post-transplant graft rejection. Graft rejection can be prevented by isolation during early period of surgery and taking immunosuppressant therapy.
Another treatment is Hepatectomy, which is the most commonly performed treatment. Limitation includes, the current state of liver function and size of future liver remnant (FLR) after surgery. Cirrhotic liver have high cancer recurrence rate, so multiple surgery is needed.
• Radiofrequency Ablation (RFA): good for small HCC (tumor less than 2 cm.)
• Trans-arterial Chemoembolization (TACE)
• Selective Internal Radiation Therapy (SIRT)
• Sorafenib: oral targeted therapy
Nevertheless, prevention is still better. Hepatitis B vaccine should be administered during childhood. If there’s no hepatitis B, there is less chance of liver cirrhosis, thus less chance of HCC.
n MEDICAL FORUM NO. 259
Cervical Cancer: Is It Preventable?
he Cervix is the entrance between vagina and uterus. Cervical cancer is the second most common cancer among women worldwide, and is the leading cause of cancer-related deaths among women in the developing countries. It occurs when normal cells change into cancer cells and this usually takes 10 to 30 years. Cervical cancer is preventable and curable on early stage.
The cause is HPV (Human Papilloma Virus). The DNA virus infect the skin (epithelial or mucosa) cells. It is a common virus which is easily spread through skin to skin contact even without sexual penetration. Most women will get infected by the HPV at one point in their lives. Half of the time, this will be an oncogenic type of HPV.
The risk factors include persistent and chronic infection with high risk oncogenic or cancer-causing type of HPV, increased number of pregnancies, history of smoking, long term use of oral contraceptives, sexually transmitted infections, sexual behavior: early onset of sexual intercourse, multiple sexual partners and having partners with multiple partners.
The symptoms are usually diagnosed late because early stage cervical cancer produces no symptoms. Some late stage symptoms include vaginal bleeding after intercourse or between menstrual periods or after menopause, watery bloody vaginal discharge that may be heavy and foul smelling, pelvic pain or pain experienced during intercourse.
As for prevention the following are recommended:
• reduce high-risk sexual behavior by having lifetime mutual monogamy
• reduce or avoid exposure to HPV and other sexually transmitted infection
• identifying and treating precancerous lesions before they progress to cervical cancer through screening tests
• administerCervical Cancer Vaccine
HPV Vaccine: can prevent most cases of cervical cancer and protect against some of the most common types of HPV. For most benefit, person should complete all 3 doses before sexual activity begins. Some examples are Cervarix, which are given to females only; and Garadsil which can prevent some vaginal and vulvar cancers of females, and genital warts of males
Tests should be started about 3 years after start of sexual activity, but not earlier than 21 years old. The tests can be:
• Pap Smear—gold standard in the country, but higher cost
• Visual Inspection with Acetic Acid Wash (VIA)—lower cost
• HPV DNA Test—detects cell change caused by HPV infection
• Biopsy—confirms presence of cervical cancer
Treatment can be via surgery or chemotherapy with concomitant radiotherapy.