Gall stone disease is a medical condition in which stone like material develops in an organ called as gall bladder that lies in the abdominal cavity on the right side and beneath the liver.

Functionally gall bladder is related with the liver as it serves as a reservoir of bile juice (secreted by the liver) and empties it into the intestine and aids in the digestion of food along with liver.

Who gets gall stones?

Incidence is more in the following category of people starting with “F”

Fat: Obese people
Female:
Forty: Incidence increases after 40.
Fertile: Pre-menopausal fertile age & this is attributed to the hormonal effect of estrogen. Estrogen is thought to increase the cholesterol secretion and the excess of which can contribute to the stone formation especially the cholesterol type. For the same reason this types of stones are seen more frequently in women especially who are fertile and obese.
Fair- Caucasian race; it is also common in Native Americans and Mexican Americans & less frequently seen in Asians and Africans.

What causes them?

The formation of gall stones is a complex process & several factors contribute for the formation of these concretions and include;

• Diet factors
• Inherited tendency
• Body weight (obesity)
• Hormonal factors (estrogen) including contraceptive pill usage
• Gall bladder motility etc.

When the fine physiological balance among bile secretion, flow and the concentration of certain substances like cholesterol and calcium bilirubinate is deranged there is a tendency for super saturation of bile acid with these substances which then favors the precipitation of them in the form of microscopic crystals and then over a period of time they gradually increase in size to become macroscopic stones.

Types of gall stones

Generally of 3 types and they are;

1. Cholesterol stones; the commonest and by definition needs to contain at least 70% of cholesterol.
2. Pigment stones; contain mostly calcium & bilirubin derivatives and less than 20 % cholesterol and usually seen in patients with cirrhosis and chronic hemolysis and also more frequent in Asian population.
3. Mixed stones; have a chemistry of both cholesterol and pigment stones, and the cholesterol content is between around 20 and 70%.

Clinical manifestations

The symptoms presented by the patients generally include;

• No symptoms at all (Possible)
• Abdominal pain (mostly right sided), may radiate to right shoulder or scapular area
• Nausea
• Vomiting
• Yellowing of skin, urine and eyes (Jaundice)
• If gall bladder gets infected then;
  • Fever
  • Chills

Complications:

• Cholecystitis: gall bladder infection secondary to the presence of stones.
• Pancreatitis: due to the blockage of common bile duct.
• Cancer of gall bladder (rare but possible).

Diagnosis

The investigations generally useful for the diagnosis & evaluation of gall stones include;

• Blood tests (cell count, electrolytes, Liver Function Tests, serum amylase & lipase)
• Ultrasound (U/S) of abdomen
• X ray abdomen
• CT abdomen
• MRI with MRCP
• HIDA Scan (using Technetium-99m)
• ERCP
• Endoscopic ultrasound (more useful for stones in the distal bile duct) etc.

U/S is probably the single most useful test. It is highly sensitive and specific for the detection of gall stones. Being also relatively less expensive and non invasive increases further its acceptability. This procedure may be performed endoscopically by mounting the transducer to the endoscopic instrument (endoscopic ultrasound).

X-ray is a basic radiological procedure and it can pick up many gall stones although not as useful as U/S.

CAT scan is an advanced radiological procedure. It is less sensitive compared to ultrasound but if diagnosis is uncertain then CAT scan has a major role by looking for other abdominal conditions.

MRI uses magnetic impulses to produce the image and it is another very helpful test. It is contraindicated in patients having metallic devices or pieces in their body and also expensive compared to U/S & CAT scans so routinely not used.

HIDA Scan: This test is extremely sensitive and specific for gall bladder diseases like stones, infection (cholecystitis) etc. However generally a U/S is obtained first because of the advantages of it as mentioned above and if U/S is negative then HIDA scan is an option.

During this test a radioisotope is injected through a vein and later pictures are taken by using special camera and it may show blockage of the passage of the dye through the biliary tree.

With the ERCP (endoscopic retrograde cholangiopancreatography) the dye is injected to the opening of bile and pancreatic duct (ampulla of vater) in the intestine by endoscopic technique with passing an instrument through the throat, esophagus and stomach and x-ray films are taken to look for obstructive pathologies like stones. MRCP is the magnetic resonance equivalent of this procedure and has the advantage of being noninvasive and now-a-days finding an increasing role in this setting.

Differential diagnosis

A myriad number of abdominal conditions can mimic or be confused with symptomatic gall stones. However a meticulous and methodical clinical analysis in conjunction with properly chosen and interpreted investigations can arrive at the correct diagnosis in most of the cases. Some common conditions which can be confused are;

Appendicitis: usually right lower abdominal pain
Kidney stones: usually pain radiates from loin to groin
Pancreatitis: diffuse abdominal or epigastric pain may radiate to back
Gastritis & ulcers: usually epigastric pain, relation to food intake, vomiting blood, passing dark colored stools etc.
Tumors of abdomen: weight loss, sub acute to chronic history, swelling of abdomen due to growth or fluid accumulation in abdomen (ascitis).

Management

Acute/ immediate cares include;

• Stabilize the patient
• Hospitalize if necessary
• Symptomatic treatments including
  • Pain killers
  • Anti nausea/ anti emetics etc
• Treat infection if cholecystitis (gall bladder infection present)

Definitive treatments include;

• Asymptomatic stones: treated expectantly.
• Symptomatic stones:

- Non surgical managements include;

• With bile acid preparations like Ursodiol. Although appealing as it may obviate the surgical needs however it has to be taken for long time and also if discontinued stones recur. In addition it is not a 100 % guarantee against stones.
• Lithotripsy (ultrasound technique): avoids surgery but useful for small stones and few numbers only.

- Surgical managements include;

• Cholecystectomy
• Endoscopic retrograde sphincterotomy for bile duct stones

Choecystectomy is the most definitive surgery (either open or laparoscopic). Some patients may develop post cholecystectomy syndrome (chronic abdominal pain, diarrhea etc).

Preventive measures include;

• Dietary measures (no adequate proof so far)
• Regular exercise may reduce the frequency of cholecystectomy.
• Using non hormonal birth control plans

Synopsis

Gall stones are not infrequent.

Particularly patients with these profile including; a middle aged, pre-menopausal, obese white lady possibly also using hormonal contraceptive pills if experiences a right sided abdomen pain, instead of downgrading the symptoms as just some gas, indigestion or acidity should consult her physician promptly and get evaluated.

Portal hypertension or increased blood pressure in the portal vein system results due to varied causes and has serious health implications.

Portal vein is a large tube like structure that brings blood from the various organs of the belly to the liver and its normal pressure is generally between 5 and 10 mm Hg. If the pressure is above around 10 to 12 mm Hg it is called as portal hypertension.

Anatomical details

The portal vein is about 8 centimeters long in adults and is formed by the union of two other veins named superior mesenteric & splenic veins (may be few other tributaries too). It normally receives the blood from the entire gastrointestinal (GI) tract and this blood is rich with all kinds of nutrients as the food digestion and absorption occurs in the GI tract.

It supplies this nutrition rich blood to the liver. It enters the liver through an area called porta hepatis where it divides into right & left branches and supplies the functional right & left lobes of liver. These branches divide and subdivide until very narrow branches called as portal venules that along with similar branches from hepatic artery pour their blood into a capillary network called as hepatic sinusoids. These sinusoids supply the liver cells the nutrients and then collect the waste products and flow in the other direction from the portal & hepatic artery area and drain into hepatic venules. These venules unite and ultimately form hepatic veins that empty their blood into Inferior vena cava and eventually the blood reaches the right side of the heart.

The portal system is anatomically connected with the systemic circulation (the blood vessels connected with the heart & rest of the body) through anastomotic channels however normally they are not operational so the blood in the portal system goes to liver and not to systemic circulation. However whenever the portal hypertension results the blood in the portal system starts using these anastomotic channels and this can produce grave consequences.

Causes of portal hypertension

The three causes are;

• Pre-hepatic
• Hepatic
• Post-hepatic

Pre-hepatic: This term is used when the blockage to portal blood flow takes place before portal vein enters the liver and generally produced by;

• Thrombosis of the splenic vein
• Thrombosis of the portal vein
• Compression of the portal vein by any structures or growths from outside

Hepatic causes: By and large about 90 to 95% of portal hypertension results due to pathologies related with the liver. There are myriad liver diseases including infections, inflammatory, congenital, genetic etc that can cause portal hypertension. Portal hypertension results due to advanced state of these diseases where there is obstruction to the portal blood flow within the liver tissue. Varieties of cirrhotic and other advanced liver diseases can induce portal hypertension.

Post hepatic: This term is used when hepatic veins and their subsequent drainage to the heart are affected and important causes include;

• Budd-Chiari syndrome
• Inferior vena cava thrombosis
• Heart diseases;
  • severe heart failure
  • constrictive pericarditis
  • restrictive cardiomyopathies

Clinical manifestations & complications of portal hypertension

The increased portal venous blood pressure has serious consequences and such outcomes are generally the result of these developments;

• Gastroesophageal varices
• Ascitis
• Splenomegaly

The gastroesophageal varices are abnormal anastomotic blood vessel connection between the portal and systemic venous system. Normally these channels are non functional however due to portal hypertension the increased portal pressure activates these blood vessels and blood starts flowing through them and if the portal blood pressure increases further then these anastomotic vessels are not equipped to handle this abnormal flow and their walls progressively weaken and eventually some of them bleed.

Cirrhosis is the commonest cause of portal hypertension and studies associated in this setting showed that majority of cirrhotic patients develop these varices during their life time and about 30% of them develop bleeding. The death rate is high with major bleedings. Also majority of these first time bleeders will develop recurrent bleedings.

Ascitis or collection of fluid in the belly cavity (abdominal cavity) is a common complication of portal hypertension. The health hazards of ascitis include intravascular volume depletion, electrolyte abnormalities, decreased perfusion of kidneys and other organs and also predisposition to peritoneal infections. A large & tense ascitis is an independent risk factor for variceal bleeding.

Splenomegaly or abnormally enlarged spleen results due to severe back pressure created by portal hypertension. This generally results in a state called “hyper-splenism” where the spleen starts destroying the blood cells including white blood cell (WBC), red blood cells (RBC) & platelets. Reduction in; WBC makes you susceptible to infections, RBC causes anemia and platelets results in bleeding.

Diagnosis

If patients with suspected portal hypertension are seen for the first time they may require extensive investigations as the cause for portal hypertension (mostly cirrhosis) needs to be established too.

The following investigations are required generally to establish the cause like cirrhosis;

• LFT (liver function tests)
• Additional blood tests (non blood tests too)
• Ultrasound
• CAT scan
• MRI
• Cholangiography
• ERCP
• Echocardiogram
• Liver biopsy etc

LFT: These are a group of blood tests somewhat routinely performed when you suspect a liver pathology and they are not specific for any particular conditions rather provide an insight into the functioning status of the liver & related structures.

These LFT may be ordered in the evaluation of cirrhosis;

• SGPT (ALT)
• SGOT (AST)
• Bilirubn (total & direct)
• Alkaline phosphatase (ALP)
• GGT (gamma-glutamyl transpeptidase)
• 5’ nucleotidase etc

Out of these tests the last three are more suggestive of what is called as cholestasis (blockage of bile flow) and other tests are more suggestive of liver cell injury.

Additional blood tests (non blood tests too);

• Hepatitis viral tests
• Hemochromatosis tests (serum iron studies, HFE mutation analysis etc)
• Wilson disease (ceruloplasmin, urine 24 hours copper, liver biopsy etc)
• Cystic fibrosis (sweat test, CFTR gene mutation)
• Alpha 1 AT levels & genotyping
• AMA (anti- mitochondrial) antibodies for primary biliary cirrhosis
• P-ANCA – for primary sclerosing cholangitis
• ANA, ASMA etc for autoimmune cirrhosis

Hepatitis viral tests:

Hepatitis B: The usual serological tests performed include;

• HBsAg
• Anti-HBs
• Anti-HBc
• HBeAg
• Anti-HBe
• HBV DNA quantitative level

Hepatitis C:

• Anti-HCV
• Quantitative HCV RNA testing

Imaging studies:

The U/S, plain x-ray, CAT scan , MRI are all imaging studies and provide us with pictures of the liver. U/S uses ultrasound, CAT scan uses x-rays and MRI uses magnetic impulses to obtain the pictures. Plain x-ray of abdomen & liver is not enough for the cirrhosis diagnosis although it might be used to look for associated conditions like ascitis etc.

Based on a study showing the utility of U/S, CAT scan & MRI of liver for the diagnosis of cirrhosis the diagnostic accuracy was 64% for U/S, 67% for CAT scan& 70.3% for MRI. In other words based on this study any of these radiological tools may be used and the final choice will depend upon other factors too like cost, any contraindications, are we also looking for additional pathologies etc.

Tests like cholangiography & ERCP (endoscopic retrograde choangiopancreatography) are occasionally required to assist with the diagnosis of PBC. Cholangiography looks for biliary tree obstruction by x-ray techniques after injecting a radio-opaque dye into the liver by a needle insertion through skin. With the other procedure the dye is injected to the opening of bile and pancreatic duct (ampulla of vater) in the intestine by endoscopic technique with passing an instrument through the throat, esophagus and stomach and x-ray films are taken to look for obstructive pathologies.

Echocardiogram may be necessary if cardiac cause of cirrhosis is suspected.

During liver biopsy a piece of liver tissue is taken out and studied under the microscope and looked for tell-tale pathological signs of cirrhosis including fibrosis, nodular pattern, cellular death etc.

If cirrhosis has already been diagnosed then the diagnosis of portal hypertension may be reliably made if patients develop certain characteristic new findings like; decreased platelets in the blood, enlarged spleen, decreased consciousness (hepatic encephalopathy), ascitis, and esophageal varices with or without bleeding. Esophageal varcices are best diagnosed by endoscopy during which a flexible tube is passed through the throat and the inner lining of esophageal mucosa is directly visualized.

U/S, MRA (MRI technique for blood vessels) and special CT sequences can show anastomotic blood vessels which are indirect but reliable evidences of portal hypertension. If diagnosis is still in doubt then special interventional radiological studies are necessary to demonstrate elevated pressure in the portal vein.

Management

Management of portal hypertension includes the treatment of the complications as well as the cause of it like cirrhosis etc.

Management of complications;

1) Management of variceal bleeding;

• Arterial constrictors like octreotide or somatostatin (constrict bleeding vessels)
• Sengstaken-Blakemore balloon-temponade (apply pressure to bleeding vessels)
• EVL (endoscopic variceal ligation) (tie the bleeding vessels)
• Sclerotherapy (vaiceal injection therapy) – shrink the bleeding vessels
• Transjugular intra-hepatic porto-systemic shunting (relieve the excessive pressure)
• Medications like beta blockers for prevention of bleeding

2) Ascitis management;

• Drainage of fluid (if large)
• Low salt intake
• Spironolactone (diuretics)
• Shunting procedures
  • peritoneo-venous shunting
  • trasjugular intra-hepatic portosystemic shunting

3) Hypersplenism:

• Generally conservative measures
• Splenectomy (rarely)

Management of cirrhosis is approached along the standard lines.

Cirrhosis is a grave form of liver disease and has multiple causes including both infectious and non infectious ones.

Cirrhosis is a histo-pathological diagnosis in the sense the definitive diagnosis is arrived by demonstrating certain characteristic findings under microscope that are suggestive of an advanced injury to the liver cells with a piece of liver tissue obtained from the patient.

Although there are many causes for cirrhosis the clinical manifestations in general do not differ a lot. The development of cirrhosis indicates that the disease is pretty advanced and brings a host of complications with it including a threat of death. One silver line in the dark cloud for these patients is cirrhosis is not always irreversible as once thought to be. If the offending agent is treated as in the case of viral causes, or the exposure to the offending agent is avoided as in the cases of alcoholism then reversal of cirrhosis has been observed in few of such patients.

Causes of cirrhosis

There are multitudinous causes and some of them include;

• Chronic alcoholism
• Chronic viral hepatitis
  • Hepatitis B
  • Hepatitis C
• Biliary cirrhosis
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • autoimmune cholangiopathy
• Non-alcoholic steatohepatitis
• Cardiac cirrhosis
• Inherited metabolic liver diseases
  • hemochromatosis
  • Wilson disease
  • Alpha 1 antitrypsin deficiency (alpha 1 AT)
  • Cystic fibrosis
• Cryptogenic cirrhosis (cause unidentified)

How do these agents induce Cirrhosis?

It all starts with injury to the liver cells and if such injuries are persistent then certain irreversible changes take place in the liver tissue affecting its functional abilities.

For example with alcohol it is assumed that some of its metabolites like acetaldehyde that are highly reactive and form complexes with proteins and such complexes are thought to interfere with various enzymatic activities. Later certain chemicals called as cytokines are secreted in abnormal amounts and they perpetuate the liver cell injury as well as stimulate the production of fibrous structures like collagen which starts getting deposited in the liver tissue. As more and more liver cells die the shrinkage of liver takes place along with its functional deterioration too. Liver architecture assumes a nodularity pattern too. Cells degenerate and regenerate although the first process will dominate.

With chronic viral hepatitis cases a characteristic micro & macro nodular pattern is seen. Patients with autoimmune cirrhosis show inflammatory cells in the liver during biopsy. The PBC patients show a necrotizing inflammatory process of the portal tracts. Cardiac cirrhosis patients initially develop a swollen enlarged liver. The long term passive congestion as well as decreased blood supply to the liver results in the damage to the liver cells and initiate the fibrosis process.

Clinical manifestations

Cirrhosis development is a long process and patients characteristically start with mild symptoms that are gradually progressive and some of the common symptoms include;

• Loss of appetite
• Loss of weight
• Jaundice (yellowish discoloration of skin, sclera, and urine etc)
• Distended abdomen (due to ascitis-fluid accumulation)
• Swelling of legs (edema)

Commonly observed clinical findings include;

• Jaundice
• Ascitis (distended abdomen)
• Edema of legs
• Spider naevi (tiny blood vessels with a spider pattern on the skin)
• Malnourishment etc.

Diagnosis

The following investigations may be required for the confirmation and management of the cirrhosis;

• LFT (liver function tests)
• Additional blood tests (some non blood tests too)
• Ultrasound
• CAT scan
• MRI
• Cholangiography
• ERCP
• Echocardiogram
• Liver biopsy etc

LFT: These are a group of blood tests somewhat routinely performed when a liver pathology is suspected and they are not specific for any particular conditions rather provide an insight into the functioning status of the liver & related structures.

These LFT may be ordered in the evaluation of cirrhosis;

• SGPT (ALT)
• SGOT (AST)
• Bilirubn (total & direct)
• Alkaline phosphatase (ALP)
• GGT (gamma-glutamyl transpeptidase)
• 5’ nucleotidase

Out of these tests the last three are more suggestive of what is called as cholestasis (blockage of bile flow) and other tests are more suggestive of liver cell injury.

Additional blood tests (some non blood test too);

• Hepatitis viral tests
• Hemochromatosis tests (serum iron studies, HFE mutation analysis etc)
• Wilson disease (ceruloplasmin, urine 24 hours copper, liver biopsy etc)
• Cystic fibrosis (mutation of CFTR gene, sweat test)
• Alpha 1 AT levels & genotyping
• AMA (anti- mitochondrial) antibodies for primary biliary cirrhosis
• P-ANCA – for primary sclerosing cholangitis
• ANA, ASMA etc for autoimmune cirrhosis

Hepatitis viral tests:

Hepatitis B: The usual serological tests performed include;

• HBsAg
• Anti-HBs
• Anti-HBc
• HBeAg
• Anti-HBe
• HBV DNA quantitative level

Hepatitis C:

• Anti-HCV
• Quantitative HCV RNA testing

Imaging studies:

The U/S, plain x-ray, CAT scan , MRI are all imaging studies and provide us with pictures of the liver. U/S uses ultrasound, CAT scan uses x-rays and MRI uses magnetic impulses to obtain the pictures. Plain x-rays of abdomen & liver are not enough for the cirrhosis diagnosis although it might be used to look for associated conditions like ascitis etc.

Based on a study showing the utility of U/S, CAT scan & MRI of liver for the diagnosis of cirrhosis the diagnostic accuracy was 64% for U/S, 67% for CAT scan& 70.3% for MRI. In other words based on this study any of these radiological tools may be used and the final choice will depend upon other factors too like cost, any contraindications, are we also looking for additional pathologies etc.

Tests like cholangiography & ERCP (endoscopic retrograde choangiopancreatography) are occasionally required to assist with the diagnosis of PBC. Cholangiography looks for biliary tree obstruction by x-ray techniques after injecting a radio-opaque dye into the liver by a needle insertion through skin. With the other procedure the dye is injected to the opening of bile and pancreatic duct (ampulla of vater) in the intestine by endoscopic technique with passing an instrument through the throat, esophagus and stomach and x-ray films are taken to look for obstructive pathologies.

Echocardiogram may be necessary if cardiac cause of cirrhosis is suspected.

During liver biopsy a piece of liver tissue is taken out and studied under the microscope and looked for tell-tale pathological signs of cirrhosis including fibrosis, nodular pattern, cellular death etc.

Complications

Once cirrhosis sets in a host of complications will accompany it and they include;

• Malnutrition
• Portal hypertension
• Hepatic encephalopathy (decreased consciousness due to liver disease)
• Bleeding tendencies
• Bone diseases (thinning of bone, fractures etc)
• Spontaneous bacterial peritonitis (peritoneal infection)
• Hepato-renal syndrome (kidney dysfunction secondary to liver disease)
• Hepatocellular carcinoma (liver cancer) etc.

Management

General measures applicable to all types of cirrhosis;

• Stabilize the patient
• Hospitalize if necessary
• Nutritious diet
• Management of complications

Measures applicable to specific types of cirrhosis include;

Alcoholic cirrhosis:

• Cessation of alcohol use (few patients see reversal of cirrhosis!)
• Steroids (may prolong survival)
• Pentoxifylline

Cirrhosis secondary to chronic Hepatitis B & C;

• Antiviral therapy (lamivudine, adefovir etc)

Hemochromatosis (regular therapeutic phlebotomies)
Wilson’s disease (copper chelating medications)
Alpha 1 AT deficiency (liver transplantation is the only option)
Cystic fibrosis (urodeoxycholic acid)
PBC (ursodeoxycholic acid)
Primary sclerosing cholangitis (ursodeoxycolic acid)
Cardiac cirrhosis (treating the underlying heart disease)

Liver transplantation is generally required for majority of these patients.

Synopsis

Cirrhosis represents an advanced form of liver damage and is caused by myriad factors.

Some of these cirrhotic conditions are preventable if such factors are identified and remedial measures are instituted quickly (e.g. Wilson disease)

Lifestyle modification including avoiding excessive & long term alcohol intake, protected sex or avoiding such risky sexual encounters (hepatitis B, C) also are of paramount significance in avoiding encounter with this disease.

It is interesting that people talk about their digestive problems with the term regularity, because regularity – that is, order – is the answer to the problem. You eat and you eliminate; those are the basic physiological functions that keep us alive. When the elimination function blocked, it is called constipation. This is usually thought to be disease that needs to be treated with pills (laxatives). In reality, constipation is a poor function of an organ as it interacts with our environment (the food we eat). It is not a disease – but it can lead to disease – and laxatives are not the answer. It is recommended the following practices to relieve constipation:

•    Drink seven glasses of water, preferably warm, each day. Drink more if the weather is hot or you are exercising.
•    Never suppress the urge to move your bowels. The longer these undesirable substances linger inside you, the more likely cancer and reabsorption of toxins become. Also, if you override the urge, the stool thickens and harder to expel.
•    Avoid antibiotics (except, of course, in life-threatening situations when antibiotics are necessary) because they destroy the healthful bowel bacteria. Take probiotics daily, usually acidophilus, bifidus, and benign E.coli populations; they build up a healthy bowel flora. You find probiotics in the fridge section of your health food store.
•    Digestion starts with chewing well, and if everything you eat is soft, the digestion process does not function well from the beginning. There is a saying in German pertaining food: soft in, hard out; hard in, soft out. So give your teeth some work to do.

Here are some gentle herb and food remedies for constipation:

•    Prunes
•    Unsweetened prune juice
•    Flaxseed (thoroughly chewed or freshly ground is better than store-bought ground)
•    Psyllium
•    Ginger
•    Fenugreek
•    Garlic
•    Sweet violets
•    Apple

The old saying “An apple a day keeps the doctors away” might well stem from laxative benefits of apples.

Colic is a severe, spasmodic pain that occurs in waves of increasing intensity, reaches a peak, and then stops for a short time before returning. The intermittent increase in pain occurs when the muscles in the affected part of the body contract.

Babies with colic may cry inconsolably and do not seem to respond to the usual means of comforting. Although these babies are healthy and show no sign of illness, they appear to be in pain. Typically, colicky babies become irritable, go red in the face, draw up their legs and pass wind, which sometimes seems to provide relief. Episodes of colic tend to be worse in the evening.

What causes colic?

No one is sure of the exact cause, but colic is common, occurring in roughly one in 10 babies. Some doctors think the baby may be having trouble digesting food. A few studies point to milk sensitivity as a possible cause, but this has not been conclusively proven. The problem may simply be sensitivity to noises in the environment.

Colic usually appears at the age of three to four weeks and rarely lasts past four months of age.

Some researchers believe that colic may be due to a muscle spasm in an immature gastrointestinal tract. There is obviously no serious problem with digestion as a colicky baby eats well, does not vomit up and gains weight normally.

How is colic treated?

There is no specific treatment for colic but there some measures that may help. Recent research has found that the incidence of colic may be lowered among breastfed babies whose mothers eliminate cow’s milk and other dairy products from their diet.

Some doctors are now recommending that this be done even before the baby is born, which may reduce the chances of milk sensitivity in the newborn.

What can I do myself?

Swaddling or wrapping the baby firmly in a light blanket makes the baby feel more secure. Colicky babies are sometimes soothed by motion – try taking the baby for a walk or a drive but be sure you use an infant car seat or secure the carrycot firmly. Simply walking around with the baby with a sling-type carrier may also help.

Don’t try feeding the baby every time he or she cries, as this will only make the stomach more bloated.

Try not to let the baby’s crying make you overanxious or exasperated. If possible, get a break from the stress of being around a constantly crying child by asking a relative, friend or neighbour to take over for an hour or so.

When should I see my doctor?

All babies should have a check-up in the first new weeks after going home. Discuss the crying with your health visitor or that the child development clinic. Your baby’s general health will be checked and a stool sample may be taken to determine if there are any problems with the intestines.

If your baby has frequent and very watery bowel movements with greenish stools, accompanied by vomiting, the crying may be due to a gastrointestinal infection rather than colic. Call your doctor promptly if such symptoms appear.

What will the doctor do?

Your doctor will examine your baby to make sure the colic is not a symptom of other conditions. A change of diet may be tried but otherwise there is no treatment for colic, and you will simply have to wait for your baby to grow out of this problem.

Is Colic Dangerous?

As long as your child is growing normally and does not appear malnourished, there is no need to worry about colic. Parents are often concerned that a colicky baby will develop into a discontented child. However, there appears to be no relationship between colic in the first few months of life and later personality development.

Perhaps one of the most striking features of colic is the emotional stress it entails for the parents.

Symptoms of Colic

• Frequent and prolonged crying.
• Baby draws up legs, as if in pain.
• Baby goes red in the face.

Are there any Natural Remedies for Colic?

Colic should initially recieve professional medical attention, but camomile tea or an infusion of crushed fennel seeds may help relieve the symptoms. Administer in 5ml/1tsp doses.

What can I do to avoid colic?

• Burp the baby thoroughly after feeding.
• If you are breast-feeding, try avoiding milk and other dairy products. Foods in a breast-feeding mother that have been linked to colic include chocolate, wheat, eggs and citrus fruits. Try eliminating them from your diet to see if this helps reduce symptoms.
• Make sure the baby is not swallowing a lot of air as it feeds. This can cause wind and abdominal discomfort.

WARNING

Call your doctor if the baby’s crying is accompanied by diarrhoea, constipation, a fever, or any other symptoms of illness.

What causes hepatitis?
Viruses are the most frequent cause of hepatitis. Other possible causes of liver inflammation include alcohol, drugs, and certain bacterial, fungal, or parasitic infectoins.

The virus known as Hepatitis A is the cause of many cases of hepatitis. It enters the body through the mouth, grows in the intestines and is shed in the stools. It is usually caught from consuming food contaminated by faecal contact, such as when a person with unclean hands prepares food. It can also be caught by eating shellfish taken from sewage contaminated water.

Hepatitis B, also known as serum hepatitis, is spread by direct contact with infected blood, either from a transfusion, or from other body fluids such as semen. This rarely occurs as a result of blood transfusions nowadays, because modern methods of screening can identify infected blood. Other common causes of viral hepatitis include contact with contaminated needles used by drug abusers, or unprotected sexual intercourse. Hepatitis viruses C,D and E have also been identified.

Hepatitis may also result from complications arising from glandular fever and a number of other infectious diseases.

How is hepatitis diagnosed and treated?
A diagnosis is established by a review of symptoms, along with blood tests for antibodies to the hepatitis viruses. Further blood and urine tests may also show abnormalities indicating liver disease.

In may cases, no special treatment is required, except for bed rest. Appetite usually returns within a few days. People who have hepatitis should not drink alcohol or take any drugs that may effect the liver, and so aggravate the condition.

A sudden, severe from of hepatitis is rare but extremely serious. Coma often develops within hours. This severe from is seen with both hepatitis A and hepatitis B. Even with the best medical care, it can be fatal.

What can I do myself?
You can help control the spread of hepatitis by maintaining cleanliness. Always wash your hands after using the toilet and before preparing or eating food. Dishes, glasses, and utensils used by a person with hepatitis should be kept separate and boiled after they are used. However, the person does not need to be kept isolated.

When should I see my doctor?
You should see your doctor as soon as possible if you have any of the symptoms of hepatitis.

What will the doctor do?
Your doctor will check to see if the liver is enlarged or tender, and will also look for an enlarged spleen. Laboratory tests will be done to determine whether the hepatitis virus is present in your blood, stool, or urine, and to identify which virus is causing the condition.

What is the outlook for sufferers?
Most cases begin with appetite loss, general feelings of discomfort, nausea, vomiting, and fever. The skin may itch and the joints may ache.

After 3-10 days the urine becomes dark, and jaundice appears. This is yellowing of the skin and eyes, due to escessive amounts of bile pigments in the bloodstream. The stools will also become yellowish.

At this point, despite the fact that the jaundice may get worse, other symptoms start to disappear and most people begin to feel better.

Within 1-2 weeks, the jaundice will peak and then fade away during a 2-4 week period of recovery.

People with hepatitis B or hepatitis C may develop a chronic from of the disease. This can be a benign condition with no symptoms, or it can progress to cirrhosis of the liver, or liver failure.

Is hepatitis dangerous?
Hepatitis A is usually mild and generally resolves itself after several weeks with no after-effects. Hepatitis B or hepatitis C can be extremely dangerous, and even fatal. Hepatitis as a complication of other viral diseases, such as glandular fever, is only rarely serious.

SYMPTOMS

• Loss of appetite.
• Nausea and vomiting.
• Fever.
• Weakness and fatigue.
• Joint pain.
• Skin irritation.
• Dark urine.
• Yellow discoloration of the skin and the whites of the eyes jaundice.

What can I do to avoid hepatitis?

• Immunization: People at high risk of Hepatitis B for example, male homosexuals or sexual partners of hepatitis B carriers can now be immunized with a new vaccine against this strain.
• Immune serum globulin: People known to have been exposed to hepatitis A can be given immune serum globulin. There is also a vaccine against Hepatitis A available.
• Personal cleanliness and habits: Maintain good personal hygiene and do not eat food that has been prepared under questionable conditions. Do not abuse drugs or share needles for any purpose.
• Blood transfusions: If receiving a blood transfusion in a foreign country, be sure the blood has been screened for contamination with Hepatitis B.

Itching, pain, bumps, and sores on the inside of the cheeks and in other areas within the oral cavity may all be categorized as mouth ulcers until a more specific diagnosis can be established. The most common types of mouth ulcers are as follows:

• Aphthous ulcers are painful, greyish bumps with bright red borders.
• Herpangina is a crop of painful red sores in the mouth and throat caused by a virus.
• Leukoplakia forms yellowish-white patches that precede the development of oral cancer.
• Lichen planus is a skin disorder which often produces bluish-white patches in the mouth.

What causes mouth ulcers?

Simple injuries such as minor burns, or even scratches made by careless toothbrushing, can cause sores to erupt in the mouth. A wide variety of allergic and infectious disorders are another common cause.

Often, however, mouth ulcers cannot be attributed to any clearly identified cause. They may be localized responses to minor infections or irritations inside the mouth.

Alternatively, mouth ulcers may be symptoms of a systemic illness such as influenza.

How are mouth ulcers diagnosed and treated?
Different types of mouth ulcers are recognizable to doctors. Tests, including a biopsy, are sometimes needed to help clarify the diagnosis.

The treatment depends on the diagnosis. Some forms of mouth sores can be relieved with local remedies, but topical medications are often difficult to apply inside the mouth since they are quickly washed away and swallowed in the saliva. Consequently, systemic treatment with pills may be required.

What can I do to relief mouth ulcers?

If pain, itching, bumps, or rough areas develop inside your mouth, you may be able to relieve the discomfort effectively with home remedies, such as sucking on an ice cube or rinsing the mouth with warm salt-water.

Non-prescription drugs may also help. For relief of pain, soluble aspirin in the form of a mouth rinse or gargle may be helpful. Your pharmacist may also be able to recommend a soothing mouth-wash, spray or lozenge containing a local anaesthetic, or a demulcent such as gelatin, glycerin or pectin which covers and protects irritated inner mouth surfaces, and speeds healing.

When should I see my doctor?

If you have a very itchy, painful, or bloody sore, or if the sore has an odd texture or taste, you should see your doctor or dentist.

What will the doctor do?

He or she will start by examining your mouth, using a light and a tongue depressor. The doctor may take a biopsy specimen in order to study the cells. This is an aid to differentiating lichen planus from leukoplakia and other stubborn oral sores, including cancers.

The doctor may prescribe mouth rinses with the anaesthetic lignocaine or another pain reliever, to be used just before eating, to help ease discomfort. Corticosteriod pills are often prescribed to relieve pain, itching, and inflammation. Other drugs, such as retinoids which are derived from vitamin A, may also be used.

What is the course of mouth ulcers?

The body seems to cure the majority of mouth ulcers over time. Those that persist may have a serious underlying cause.

When lichen planus appears in the mouth, it is likely to spread to different sites on the skin. It may eventually disappear without treatment, although it tends to recur. Herpangina, on the other hand, usually occurs once only.

Are mouth ulcers dangerous?

Most are not. A few are, however, and medical evalution is necessary to tell the dangerous ones from the harmless ones.

SYMPTOMS

• Itching or pain.
• Bumps, rough areas, or ulcers in the mouth.
• Visible discolouration of the oral membranes.
• Bleeding from the mouth.

ALTERNATIVE  TREATMENTS

Practitioners of alternative medicine offer the following treatments for mouth ulcers:

• Herbal medicine
  Herbalists generally view mouth ulcers as a symptom of being run down, so their treatment will concentrate just as much on the overall health of the patient as curing the ulcer. Swilling with a mouth-wash of tincture of myrrh- available at chemists and health food shops- every two hours, may be advised. This should clear up the condition within two days.Chewing licorice root, is sometimes suggested as it has been found to be effective in soothing and curing mouth ulcers.

• Homoeopathy
  For severe mouth ulcers, which are extemely painful, and produce a sharp pin-point pain, nitric acid 6 may often be prescribed by a homoeopath.

What can I do to avoid mouth ulcers?

• Practice good oral hygiene dy brushing and flossing teeth regularly.
• Since tobacco use contributes to mouth ulcers, give up smoking, taking snuff and chewing tobacco.
• Drink alcohol in moderation as excessive consumption increases the likelihood of mouth ulcers.

Warning / Precaution

If an ulcer, sore or lump persists in your mouth for longer than one month, see your doctor or dentist- it could be a sign of cancer.

Mouth ulcers are common and usually clear up within seven to 10 days. However, some ulcer-like growths in the mouth or on the tongue can be malignant. Early detection of a malignant growth is essential, so any lump or growth in the mouth area which persists for more than one month should be investigated by your doctor.

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal problems or digestive disease. It is characterized by colicky abdominal pain and an increased frequency of bowel movement. the condition often develops in adolescence or young adulthood, and often flares up during times of stress.

What causes Irritable Bowel Syndrome?

Irritable bowel syndrome is known as a functional disorder because no underlying cause for it has been identified. Peristalsis, the movement of digested food through the intestines, occurs as the result of rhythmical muscular contractions. In some people with IBS, the contractions are irregular and abnormally strong.

In others the contractions may be normal, or may be exaggerated, rather than abnormal. There may be spasms of pain and an excess or decrease of fluid inside the bowel.

How is Irritable Bowel Syndrome diagnosed and treated?

In those who are under 35 and in generally good health (apart from IBS), diagnosis is likely to be based on symptoms alone.
Tests may be necessary to rule out other disorders with similar symptoms, such as an inflammatory bowel disorder (Crohn’s disease, for example), or certain types of gastrointestinal cancer.

These tests may include rectal examination, sigmoidoscopy (in which a viewing device is used to examine the rectum and part of the large intestine), and barium x-rays (which provide an image of the digestive tract).

Occasionally, a colonoscopy (in which the main part of the large intestine is examined with a viewing device) may be carried out.

Such tests are essential in older people as the risk of more serious diseases with similar symptoms increases with age.
Treatment aims to minimize discomfort and to reestablish a normal pattern of bowel movements. Your doctor will counsel you on diet and lifestyle and may prescribe medications to add bulk to your stool.

For severely painful episodes, other drugs may be prescribed to reduce intestinal spasm.

What can I do myself?
A variety of lifestyle measures can help to regulate the bowels. Some suggestions include:

• Keep a diary to identify the lifestyle factors that trigger attacks.
• Take regular exercise.
• Avoid excessive tea, coffee and alcohol.
• If flatulence is a problem, avoid beans, cabbage, and any other foods which may trigger intestinal gas.
• Some doctors recommend a high-fibre diet, although there is no established link between high fibre and gastrointestinal disorders.

Those who wish to try this should obtain their fibre from vegetables, rice, fruit, and so on, rather than bran, which may worsen the condition. If a high-fibre diet does not help, or makes it worse, a bland diet may help.

Irritable bowel syndrome is a highly variable disorder which affects individuals differently. So, it is important to identify, and then avoid foods or activities that may worsen your condition. Since the primary treatment for the disease is a change in lifestyle, rather than medication, you need to learn more about your bowel’s response to your habits.

For example, some people may find they react badly to certain foods. Sometimes, simply eating smaller meals can help.
Since tension often worsens the disorder, relaxation therapy or psychotherapy can help you cope better with stress. Self-hypnosis has been of benefit to some people.

When should I see my doctor?

You should report any persistent deviation in your bowel habit to your doctor. If you are already under treatment for irritable bowel syndrome, call your doctor if you experience any prolonged change or worsening of your symptoms, or pass blood in the stools.

Is Irritable Bowel Syndrome dangerous?
No, but sufferers can experience some amount of discomfort.

Symptoms of IBS

• Absence of a regular pattern of bowel movements.
• Frequent diarrhoea, constipation, or alternating bouts of each.
• Bloating or swollen abdomen.
• Abdominal pain and/or cramps.
• Excessive gas or flatulence.
• Related symptoms may include fatigue, depression and anxiety.

How can I avoid Irritable Bowel Syndrome?

• A high-fibre diet which promotes efficient bowel function may help to prevent the symptoms.
• When you know you are likely to be under extra stress, special attention to diet, exercise and relaxation may be able to help, or supplementary medication may be necessary
• Avoid over-eating and eating at irregular hours

Warning / Precaution

Any persistent change in bowel habit should be checked by a doctor, as this may be a warning symptom of colon cancer. In fact, for a more cautious approach, any symptoms of pain or cramp associated with change of bowel habit should be consulted with a doctor immediately.

A biopsy of sample tissue taken from a tumour, lesion or other suspicious area may be removed for further examination to establish a diagnosis of colon cancer. Such investigations might include a barium enema, a sigmoidoscopy or a colonoscopy.

A barium enema involves infusing a chalky substance into the rectum, in order to outline the colon on an X-ray. With a sigmoidocopy, a short flexible tube is inserted for a colonoscopy, which allows the colon to be examined along its entire length Some tissue samples may also be removed for analysis during this procedure. Colon cancer is treated by surgical removal of the tumour, along with a portion of the colon above and below the cancer, to make sure that all of it is removed. The lymphatic tissue that drains the area is also removed and studied for any signs of possible spread.

Usually the two ends of the colon are rejoined and will function normally after surgery. Occasionally a colostomy (an opening between the colon and the surface of the body which allows faecal matter to be evacuated from the colon) may be necessary. This is often just a temporary measure in order to allow healing of the bowel area where the tumour has been removed.

When Should I See My Doctor?

You should see your doctor as soon as possible if you notice any warning symptoms of colon cancer. As the likelihood of colon cancer increases with age, some doctors recommend that people over 50 years of age, especially high-risk individuals should have a sigmoidoscopy (when the rectum and colon are examined with a flexible viewing tube) every three to five years.

What Will The Doctor Do?

Your doctor will probably carry out a physical examination and arrange for any further tests or X-rays. You may be referred to a hospital for these to be carried out.

What Can I Do Myself?

The best thing that you can do if you have any symptoms of possible colon cancer is to see your doctor as soon as possible. Colon cancer is curable if it is diagnosed and treated early enough. Unfortunately many people put off seeing their doctors until the cancer is at an advanced stage, which makes a cure more difficult to achieve.

Is Colon Cancer Dangerous?

Although colon cancer is a dangerous condition, over half of those treated surgically survive for more than five years after operation. The earlier the cancer is diagnosed and treated, the better the chances are there for a cure.

Who Has Higher Risk Of Developing Colon Cancer?

Some people have an increased risk of developing colon cancer. These risk factors include:

• family history of the disease
• polyps in the colon
• ulcerative coligtis and other inflammatory bowel diseases

If you fall into a high risk group you should see your doctor for advice about regular screening tests.

Treatments for Colon Cancer

Radiation therapy may be used either before or after surgery, and cancer chemotherapy may be given after surgery, depending upon how far the cancer has spread.

The colon makes up the majority of the large intestine, except the last 10cm, which is called the rectum. Colon cancer is a malignant in this area of the large intestine.

Most colon cancer is on the left side oin the sigmoid colon, the segment nearest the rectum. In Australia, colon cancer is one of the most common causes of death from cancer.

What Causes Colon Cancer?

The cause of colon cancer is unknown. How diet promotes cancer is not known either, but some researchers believe it plays an important role and studies have found that people who consume a diet low in fibre and high in protein and fat have a high incidence of colon cancer. It may well be related to the digestion of fats and to the speed at which faeces travel through the bowel. Fresh fruit and vegetables may act as protective factors.

Colon cancer often develops from a benign mass (adenoma) that grows from the surface fo the bowel and then spreads into the bowel channel. Adenomas range in size from the barely visible to several centimetres wide. Cancer cells may grow inside them and the larger the adenoma is, the more likely it is to contain them.

A small colon cancer can lie undetected for many years, without causing any symptoms. The growth patterns and eventual sysmptoms all differ, depending on where the cancer is located along the colon. Eventually, if it is not treated, it can spread to other body organs with fatal consequences.

What Are The Symptoms of Colon Cancer?

1. Persistant change in bowel habits (either diarrhoea or constipation)
2. Rectal bleeding
3. Lower abdominal pain or bloating
4. Change in the size or shape of the stool
5. Weight loss