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Glaucoma

Management Team

Glaucoma

Overview

Glaucoma comprises a group of eye conditions associated with damage to the optic nerve (the nerve that connects the eye to the brain) to the point where it detaches from the eye. It is one of the leading causes of vision loss globally. In the UK, approximately 2% of people aged > 40 years are reported to have glaucoma.

While any vision loss resulting from glaucoma cannot be recovered, early diagnosis, routine monitoring, and accurate treatment strategies can greatly help suppress further loss of vision and preserve eyesight long-term in most patients. Glaucoma is usually difficult to detect as there are no warning sign. Routine eye examinations will help ascertain the onset and progression of this condition.

Glaucoma may be categorised into the following four types:

  • Primary open angle glaucoma, which develops very slowly, is the most common type of glaucoma. The risk of developing this condition is high among Black African or Black Caribbean populations.
  • Angle closure glaucoma may develop slowly (chronic) or rapidly (acute) with a sudden, painful elevation of intraocular pressure. Asian populations show a higher risk for developing this condition than other ethnic groups. This is a rare condition.
  • Secondary glaucoma occurs because of other eye conditions, such as uveitis (inflammation of the uvea: the middle layer of the eye), or eye injuries.
  • Developmental (congenital) glaucoma is a serious abnormality of the eye. Usually, it develops at, or shortly after, birth. This is also a rare condition.

Most cases of glaucoma are caused by the increase in intraocular pressure resulting from the improper drainage of fluid within the eye, damaging the optic nerve. Although an exact cause has not yet been identified, certain factors have been reported to increase the risk for developing glaucoma:

  • Age (glaucoma is more common with older age).
  • Ethnicity (Caribbean, African, or Asian populations are at a higher risk).
  • Family history.
  • Other medical conditions, such as diabetes, hypertension, short-sightedness, and long-sightedness, may increase the risk for developing glaucoma.

Glaucoma rarely causes any symptoms. It develops slowly over several years, initially affecting the peripheral vision. Therefore, most people do not realise that they have glaucoma. This condition is often diagnosed only during a routine ophthalmic examination.

The presence of the following symptoms may be observed:

  • Blurry vision.
  • Appearance of rainbow-coloured circles around bright objects/lights.

Although both eyes are usually affected, glaucoma may be more severe in one eye. Occasionally, the sudden development of glaucoma has been noted along with the following symptoms:

  • Redness.
  • Blurred vision.
  • Intense eye pain.
  • Tenderness around the eyes.
  • Appearance of rings around lights or bright objects.
  • Headache, nausea, and vomiting.

Glaucoma is diagnosed by two main tests:

  • Optical coherence tomography (OCT) of the optic nerve head to rule out structural changes and thinning or loss of the retinal nerve fibre.
  • Perimetry or Humphrey Field Analyser (HFA) to assess the peripheral visual field.

Any loss of vision that has occurred before glaucoma is diagnosed cannot be reversed. However, specific glaucoma treatment methods can help stop the worsening of vision.

The recommended treatment depends on the type of glaucoma and includes:

  • Anti-glaucoma eyedrops to reduce the intraocular pressure.
  • Laser treatments to reverse the blockage of drainage tubes or reduce fluid production within the eye.
  • Trabeculectomy: A type of surgery to enhance the drainage of fluid out of the eye and reduce the intraocular pressure.
  • Microinvasive glaucoma surgery (MIGS): A type of minimally invasive eye surgery in which the intraocular pressure is lowered via the creation of small incisions. This procedure improves the natural drainage, unlike the case for traditional glaucoma surgeries, in which the drainage system is bypassed.
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Gastrointestinal Surgery

Management Team

Gastrointestinal Surgery

Overview

Gastrointestinal surgery is performed for various diseases of the gastrointestinal tract, which involves the liver, pancreas, gall bladder, stomach, and small and large intestines. The operation can be done through the conventional open method (through a cut or incision on the abdomen) or through any of the minimally invasive methods, which include either the laparoscopic method or robotic surgery.

  • Cancer of the stomach – removal of parts of the stomach for cancer and neuroendocrine tumours
  • Cancer and tumours of the small intestine
  • Large intestine cancer and large polyps – colon cancer
  • Rectal cancer
  • Inflammatory bowel disease
  • Surgery on the gall bladder for cancer and gall stones, which includes removal of the gall bladder for stone – laparoscopic cholecystectomy
  • Surgery on the pancreas for cancer and pancreatitis. The most common reason for pancreas surgery is due to cancer, when a variable portion of the pancreas is removed either through Whipple’s procedure or distal pancreatectomy depending on the location of the tumour.
  • Surgery on the liver – hepatectomy, which involves removal of part of the liver affected with cancer. Cancer might arise in the liver – hepatocellular carcinoma (HCC) or cholangiocarcinoma (CCA) or cancer that has spread to the liver from elsewhere through liver metastases
  • Surgery for large tumours in the abdomen – neuroendocrine tumours/retroperitoneal tumours and masses
  • Surgery for miscellaneous abdominal conditions – acute abdomen, including perforation/obstruction and infections.
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Gall Bladder Cancer

Management Team

Gall Bladder Cancer

Overview

Cancer of the gall bladder is the fifth most common cancer of the digestive system. In India, its incidence is higher in Northern India. Sometimes, gall bladder cancer is accidentally detected, when gall bladder is removed for gallstone diseases (incidental gall bladder cancer). This by itself is a rare occurrence, but it has been estimated that a silent cancer will reside in 0.2–3% of all cholecystectomies. Gall bladder removal is a very common operation. Rarely, cancer can be discovered in pathological examination of the gall bladder. These patients will then need a definitive treatment, and further surgery for complete removal of cancer.

  • Chronic inflammation of the gall bladder – Chronic cholecystitis
  • Gall bladder polyps > 1 cm in size: Gall bladder polyps are usually small growths that arise from the gall bladder. Most polyps are usually benign and do not carry cancer risk, but it depends on the polyp size. Polyps > 1 cm are at an increased risk of being cancerous. These patients need surgery to remove the gall bladder. As such, only 0.6% of all gall bladder polyps are malignant. However, when the size exceeds 1 cm the risk of developing cancer increases.
  • Focal thickening and irregularity/induration on the gall bladder wall–as seen on ultrasound and imaging may be associated with gall bladder cancer–and will require a cholecystectomy.

Only 30% of all gall bladder cancers are discovered preoperatively (non-incidental). The patient may present with vague symptoms including:

  • Pain
  • Vomiting
  • Weight loss
  • Jaundice.

Diagnosis is incidental and may be discovered during:

  • Pathological examination: Gallbladder cancer is rarely diagnosed, when a pathological examination of the gall bladder is done. Once this diagnosis has been established, the patient would need detailed imaging tests.
  • CT scan/PET- CT scan: Accurate diagnosis of gall bladder cancer is made on CT scanning. Further imaging (PET-CT) will be required to rule out metastases. CT scan is an accurate modality to stage the disease and define further treatment, which is stage dependent.

The precise treatment plan will depend on the presence/absence of metastatic disease, lymph nodes and local extent of the disease. In most instances, wherein the cancer is localised to the gall bladder (which is usually the case), further surgery is required

  • Surgery is the only definitive treatment with potential for cure. Hence, wherever possible, surgery should be done. Furthermore, surgery is only done, when the cancer is localised to the gall bladder and the surrounding structures including regional lymph nodes, and has not extensively spread to either within the abdomen or elsewhere. Since the gall bladder resides at the base of the liver, surgery for cancer involves

    • Gall bladder removal
    • Removal of part of the liver, wherein the gall bladder resides (segment 4b/5)
    • Regional draining of lymph nodes

    Sometimes more extensive surgery will be required to remove the cancer.

  • Chemotherapy: Surgery remains the cornerstone of management of gall bladder cancer. However, chemotherapy plays a role in the treatment and would be required following surgery. Chemotherapy is also sometimes required preoperatively prior to surgery.
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Guillain-Barre Syndrome

Management Team

Guillain-Barre Syndrome

Overview

Guillain Barre syndrome is a prevalent cause of acute neuromuscular paralysis.

Guillain Barre syndrome is an acquired neuropathy caused due to the formation of autoantibodies, which are generated in response to infections caused by Campylobacter jejuni, Cytomegalovirus (CMV), Epstein–Barr Virus, Haemophilus influenzae, and Mycoplasma pneumoniae. Common antibodies associated are ganglioside antibodies (GM1) in acute inflammatory demyelinating neuropathy (AIDP), GQ1b antibody (Miller Fisher variant), and GD1a antibody in acute motor axonal neuropathy (AMAN).

  • Bacterial or viral infection
  • Surgery
  • Age over 50 years
  • Vaccinations in rare cases

  • Gradually worsening ascending muscle weakness, sometimes accompanied by paraesthesia, with symptoms typically peaking within four weeks
  • Progressive loss of tendon reflexes
  • Back pain and radicular discomfort
  • Weakness in respiratory muscles
  • Cranial nerve dysfunction, affecting facial and bulbar muscles
  • Autonomic system involvement
  • Occasional bladder and bowel dysfunction
  • Regional variants:
    • Miller Fisher syndrome (ophthalmoplegia, areflexia, and ataxia)
    • Acute pandysautonomia
    • Acute oropharyngeal palsy (similar to diphtheria)
    • Pharyngo-cervico-brachial pattern
    • Flaccid paraparesis variant
    • Pure sensory variant

Neurologist

  • Blood tests to rule out conditions mimicking GBS like hypokalaemia, porphyria.
  • CSF examination for albuminocytological dissociation
  • Antibody measurements
  • NCV may show prolonged F waves, demyelination with/ without conduction blocks (AIDP) or axonal degeneration as in AMAN or AMSAN variants
  • MRI to determine enhancement of nerve roots

  • Intravenous immunoglobulin (IV Ig) is treatment of choice.
  • Plasma exchange (PE)
  • Disease-modifying therapy
  • General supportive management
  • Monitoring of swallowing dysfunction
  • Management of respiratory insufficiency
  • Autonomic dysfunction management- arrhythmia/ blood pressure fluctuations
  • Thromboembolic complication prevention
  • Neuropathic pain treatment with gabapentin, carbamazepine, or tramadol
  • Physiotherapy
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Gallbladder Cancer

Management Team

Gallbladder Cancer

Overview

Gallbladder cancer is a rare but aggressive cancer that develops in the gallbladder. Early detection and treatment are crucial for improving the outcomes, especially as this cancer is often diagnosed at later stages when it is more difficult to treat.

  • Adenocarcinoma: The most common type, accounting for ~90% of all gallbladder cancers. This type of cancer originates in the glandular cells of the gallbladder, which are responsible for secreting mucus and bile.
  • Adenosquamous carcinoma: A rare form of gallbladder cancer that has both glandular (adenocarcinoma) and squamous cell (flat) characteristics.
  • Squamous cell carcinoma: This type of gall bladder cancer involves the squamous cells lining the gallbladder.
  • Small cell carcinoma: A rare, aggressive form of gallbladder cancer that often spreads quickly and is typically diagnosed at an advanced stage.
  • Other rare types:
    • Sarcomas: These originate in connective tissues of the gallbladder and are extremely rare.
    • Neuroendocrine tumours: These are very rare and arise from hormone-producing cells in the gallbladder.

The exact cause of gallbladder cancer is unknown; however, several factors may contribute to its development.

  • Chronic inflammation: Persistent inflammation of the gallbladder, often due to conditions like chronic cholecystitis (inflammation of the gallbladder), increases the risk of cancer.
  • Gallstones: These may lead to irritation and inflammation, which increases the risk of cancer. Further, inflammation and infection from gallstones can promote the accumulation of genetic mutations in the gallbladder cells.
  • Bile duct abnormalities: Biliary dysplasia or abnormal changes in the bile ducts, are a risk factor for gallbladder cancer.
  • Age and gender: Gallbladder cancer is more common in people over the age of 65 and is also more common in women than men.
  • Obesity and overweight: These increase the risk of gallbladder cancer, likely due to changes in bile composition and increased inflammation in the gallbladder.
  • Family history and genetics: A family history of gallbladder cancer or other types of gastrointestinal cancer may increase the risk of developing gallbladder cancer. Genetic conditions, such as familial adenomatous polyposis (FAP) or Lynch syndrome, may also predispose individuals to gallbladder cancer.
  • Tobacco and alcohol use: Smoking and heavy alcohol consumption have been linked to an increased risk of gallbladder cancer.
  • Other medical conditions: Conditions like primary sclerosing cholangitis (a disease of the bile ducts) or porcelain gallbladder (a condition where the gallbladder wall becomes calcified) are associated with a higher risk of gallbladder cancer.

Gallbladder cancer often does not present any symptoms until it reaches an advanced stage, which makes early detection difficult. When symptoms do occur, they may include:

  • Upper right abdominal pain: The most common symptom (pain may be dull or sharp).
  • Nausea and vomiting: Often due to the obstruction of the bile ducts or inflammation.
  • Jaundice: Caused by bile buildup in the bloodstream.
  • Unexplained weight loss: Sudden and unexplained weight loss can be a sign of gallbladder cancer.
  • Loss of appetite: A common symptom in individuals with cancer.
  • Feeling of fullness or bloating: Often accompanied by a change in bowel movements.
  • Fever: Can occur as a result of an infection or inflammation in the gallbladder.
  • Dark urine: Due to the presence of excess bilirubin in the bloodstream.
  • Clay-coloured stools: Due to the inability of bile to reach the intestines.

Gallbladder cancer can be difficult to diagnose because the associated symptoms often resemble those of other conditions, such as gallstones or cholecystitis (inflamed gallbladder). The diagnostic strategy generally includes:

  • Imaging tests:
    • Ultrasound: The first imaging test often used to detect gallbladder abnormalities and tumours.
    • CT: Can detect tumours and provide information regarding the spread of cancer (if the cancer has spread to other parts of the body).
    • MRI: Useful for assessing the liver and bile ducts.
    • Endoscopic ultrasound (EUS): May be used for better visualisation, especially for small tumours.
    • Cholangiography: An X-ray or MRI-based test that helps visualise bile duct obstructions.
  • Biopsy:
    • Needle biopsy: A sample of tissue from the gallbladder is taken for examination under a microscope to confirm cancer.
    • Endoscopic biopsy: If the cancer is accessible via the digestive tract, an endoscopic procedure may be used to obtain tissue samples.
  • Blood tests:
    • Tumour marker analysis: Elevated levels of CA 19-9 and CEA (carcinoembryonic antigen) may indicate the presence of gallbladder cancer, though the levels of these markers can also be elevated in other conditions.

Treatment for gallbladder cancer depends on the stage at the time of diagnosis, whether the cancer has spread, and the patient's overall health.

  • Surgery:
    • Cholecystectomy (gallbladder removal): Primary treatment if the cancer is detected early on and is localised. If cancer has spread to nearby structures, a partial liver resection or removal of nearby lymph nodes may be required.
  • Chemotherapy (gemcitabine and cisplatin): This may be used as an adjuvant treatment after surgery or in advanced cases where the tumour cannot be surgically removed.
  • Radiation therapy: This therapy may be used to shrink tumours or relieve symptoms in cases where surgery is not an option. It is often used in combination with chemotherapy for treating advanced gallbladder cancer.
  • Targeted therapy: Targeted drugs like HER2 inhibitors may be used in cases where genetic mutations have been identified.
  • Palliative care: In advanced stages of gallbladder cancer, palliative care is provided to manage symptoms and improve quality of life, including drainage of bile ducts to alleviate jaundice.

While there is no guaranteed way to prevent gallbladder cancer, certain lifestyle changes and medical interventions can reduce the risk:

  • Removing the gallbladder: Removal of the gallbladder (cholecystectomy) in patients with gallstones can reduce the risk of gallbladder cancer.
  • Healthy diet: Eating a balanced diet with a focus on fruits, vegetables, and low-fat foods may help lower the risk of gallbladder cancer.
  • Maintaining a healthy weight: Avoiding obesity can reduce the risk of gallbladder cancer.
  • Avoid smoking and excessive alcohol consumption: These risk factors should be minimised to reduce the likelihood of developing gallbladder cancer.
  • Regular medical check-ups: For individuals at higher risk of gallbladder cancer (family history, chronic inflammation, or genetic conditions), regular screenings and medical check-ups are important for early detection.
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Gallbladder Polyps

Management Team

Gallbladder Polyps

Overview

Gallbladder polyps are growths or lesions that protrude from the lining of the gallbladder. Most are benign (non-cancerous), but some maybe malignant (cancerous), particularly larger ones.

  • Cholesterol polyps: These are the most common gallbladder polyps and are often associated with cholesterolosis. Cholesterol polyps are generally benign.
  • Adenomatous polyps: These are rue neoplasms with potential to become malignant (adenocarcinoma), and the cancer risk increases with size (>1 cm)
  • Inflammatory polyps: These occur in response to chronic inflammation, often in chronic cholecystitis.
  • Hyperplastic polyps: These are benign growths due to mucosal overgrowth, and generally, there is no cancer risk.
  • Adenomyomatosis: This entity refers to hyperplasia (overgrowth) of the gallbladder wall, not is considered a true polyp; however, it may mimic one.
  • Malignant polyps: These are rare and can progress to primary gallbladder carcinoma.

The causes and risk factors of gallbladder polyps have been enumerated below.

  • Accumulation of cholesterol and triglycerides in the gallbladder wall.
  • Chronic inflammation (chronic cholecystitis).
  • Abnormal cell growth due to genetic mutations (adenomatous polyps).
  • Association with gallstones and biliary sludge.

Risk factors

  • Individuals aged over 50 years of age are more prone to polyp development and men are at a higher malignancy risk.
  • Metabolic conditions:
    • Obesity
    • Dyslipidaemia
    • Metabolic syndrome
  • Gallbladder-related conditions:
    • Gallstones
    • Chronic gallbladder inflammation.
  • A family history of gallbladder cancer or polyps is a risk factor.

Many gallbladder polyps are asymptomatic and discovered incidentally. When symptoms occur, they may include:

  • Right upper quadrant pain
  • Nausea and vomiting
  • Bloating or indigestion
  • Jaundice (rare, may indicate obstruction or malignancy)

Various diagnostic modalities for gallbladder polyps have been enumerated below.

  • Imaging tests:
    • Ultrasound (first-line imaging): Ultrasound can detect polyps, measure polyp size, and assess gallbladder wall thickness.
    • Endoscopic ultrasound (EUS): Provides more detailed imaging, especially for small or suspicious polyps.
    • CT or MRI: Can evaluate larger polyps or suspected malignancy.
    • MRCP (magnetic resonance cholangiopancreatography): Can visualise the biliary tree and gallbladder.
  • Histological examination (if gallbladder is removed): Confirms the type of polyp and presence of cancer.

Various treatment modalities based on gallbladder polyp size have been enumerated below.

  • Small polyps (<1 cm, benign-looking): Regular follow-up with ultrasound every 6‒12 months. No treatment unless growth is detected or symptoms develop.
  • Larger polyps (>1 cm or suspicious features): Cholecystectomy (gallbladder removal): recommended due to increased malignancy risk.
  • Symptomatic polyps: Cholecystectomy is advised if symptoms like pain or inflammation occur.
  • Malignant polyps: Radical cholecystectomy may be needed, sometimes with additional liver resection or lymph node dissection if cancer is present.

Monitoring and Follow-Up

  • Polyps <6 mm with no risk factors may not need frequent follow-up.
  • Polyps 6-9 mm may require annual ultrasound monitoring.
  • Immediate surgical evaluation for polyps >1 cm.
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Gallbladder Stone Disease

Management Team

Gallbladder Stone Disease

Overview

Gallbladder stone disease, also known as cholelithiasis, refers to the presence of gallstones (solid crystals) in the gallbladder. These stones can vary in size from tiny grains to large stones and can obstruct the normal flow of bile. This blockage can lead to various symptoms, including pain and inflammation, and may result in complications if not properly managed.

Gallstones can be of various types, including:

  • Cholesterol gallstones: These are the most common type of gallstones and are usually yellow or green in colour.
  • Pigment gallstones: These are made of excess bilirubin (a substance that is released the when red blood cells break down) and are dark brown or black in colour. Pigment gallstones are more common in individuals with medical conditions, like cirrhosis, biliary tract infection, and sickle cell anaemia.
  • Mixed gallstones: These gallstones are made up of cholesterol, bilirubin, and calcium salts.

There are multiple causes and risk factors for gallbladder stone disease; these include:

  • Excess cholesterol: When the liver produces too much cholesterol, the gallbladder is not able to properly break it down; this leads to the formation of cholesterol stones.
  • Excess bilirubin: Certain conditions like liver disease or haemolytic anaemia result in increased production of bilirubin, which may then be used to form pigment gallstones.
  • Incomplete emptying of the gallbladder: If the gallbladder does not empty completely—or often enough—bile can become concentrated and form stones.
  • Obesity: Being overweight or obese results in increased cholesterol levels, thereby contributing to the formation of gallstones.
  • Pregnancy: Hormonal changes during pregnancy, particularly increased oestrogen levels, may lead to gallstone formation.
  • Diabetes: Increased blood sugar levels and high insulin levels can promote the formation of gallstones.
  • Age: The risk for gallstone disease increases after 40 years of age.
  • Gender: Women are more likely than men to develop gallstones owing to the effects of oestrogen and progesterone, which increase the cholesterol levels.
  • Family history: A family history of gallstones increases the risk of developing gallstones.
  • Cholesterol-lowering medications: Certain medications, like cholesterol-lowering drugs (e.g., statins), may increase the risk of gallstone formation.
  • Rapid weight loss: Speedy weight loss (e.g., through very low-calorie diets or weight-loss surgery) can cause the liver to release more cholesterol into the bile, increasing the likelihood of stone formation.
  • Other medical conditions: Conditions like diabetes, cirrhosis, Crohn's disease, and certain blood disorders (such as sickle cell disease) increase the risk of developing gallstones.

Many individuals with gallstones do not experience any symptoms ("silent gallstones"); however, when symptoms do occur, they can include:

  • Abdominal pain: Often in the upper right abdomen or the centre of the abdomen. Can be severe and last from a few minutes to several hours (gallbladder attack).
  • Nausea and vomiting: Especially after eating fatty foods.
  • Indigestion: Bloating, heartburn, and gas.
  • Jaundice: Occurs when a stone blocks a bile duct and prevents bile from draining properly.
  • Dark urine or pale stool: Caused by the blockage of bile flow.
  • Fever: If the gallstones cause an infection or inflammation (cholecystitis), fever and chills may occur.

The diagnostic modalities for gallbladder stone disease have been enumerated below.

  • Imaging tests:
    • Ultrasound: The most common and reliable test for detecting gallstones.
    • CT: Can be used to identify gallstones, but it is not as sensitive as ultrasound.
    • MRI: A magnetic resonance imaging (MRI) scan with a special focus on the biliary system can help detect stones in the bile ducts.
  • Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used both for diagnosing and treating gallstones that may be blocking the bile ducts. It involves using a flexible tube with a camera to view the bile ducts.
  • Blood tests: Bile duct blockage can result in elevated levels of bilirubin or liver enzymes.

Treatment depends on the symptoms manifested and the size and type of gallstones.

  • Non-surgical treatments:
    • Medications: Medications like ursodeoxycholic acid can dissolve cholesterol stones, but they are usually only effective for small stones and may take months or years to work.
    • Shock wave lithotripsy: A technique where shock waves are used to break up large stones, making them easier to pass.
  • Surgical treatments:
    • Cholecystectomy: The most common treatment for symptomatic gallstones. It involves the surgical removal of the gallbladder, usually through minimally invasive laparoscopic surgery. After this procedure, bile flows directly from the liver into the small intestine.
    • Endoscopic surgery: If the stones are stuck in the bile ducts, a procedure like ERCP may be used to remove them without requiring full gallbladder removal.
  • Dietary changes: Though dietary changes cannot result in the dissolution of existing gallstones, a low-fat, high-fibre diet can help manage symptoms and prevent new stones from forming.
  • Lifestyle modifications: Maintaining a healthy weight, avoiding rapid weight loss, and exercising regularly can help reduce the risk of developing gallstones in the future.

  • Healthy Eating: A balanced, low-fat diet with plenty of fibre can help reduce the risk of gallstones.
  • Regular exercise: Staying active can help maintain a healthy weight and reduce the risk of developing gallstones.
  • Gradual weight loss: Losing weight at a slow and steady rate can help prevent gallstone formation.
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Glomerulonephritis

Management Team

Glomerulonephritis

Overview

Glomerulonephritis is a kidney condition characterised by inflammation and damage to the nephrons, the small tubular structures that make up the kidneys. This condition can affect the kidney’s ability to filter waste and excess fluids effectively, leading to various symptoms and potential complications if left untreated.

Glomerulonephritis occurs due to active inflammation in the kidneys, often caused by:

  • Autoimmune disease, e.g., lupus
  • Infections, e.g., post-streptococcal glomerulonephritis
  • Vasculitis e.g., ANCA- associated vasculitis
  • Exposure to certain toxins and drugs

Glomerulonephritis typically manifests through a range of symptoms, which may vary in severity depending on the underlying cause. These include:

  • Haematuria: Presence of blood in the urine.
  • Proteinuria: Frothy urine due to protein leakage
  • Oliguria: Reduced urine output
  • Swelling: Puffiness around the eyes, face, or legs.
  • Systemic symptoms include fever, joint pains or rashes over other parts of body.

For the diagnosis and management of glomerulonephritis, it is essential to consult a kidney specialist (Nephrologist)

The following tests and procedures are commonly performed to diagnose glomerulonephritis:

  • Urine tests: Routine microscopy and protein creatinine ratio.
  • Blood tests: Renal function tests, complement levels (C3, C4) and autoimmune markers like ANA, c-ANCA, and p-ANCA.
  • Kidney biopsy: In some cases, a biopsy may be required for definitive diagnosis.

The treatment approach varies depending on the underlying cause and severity of the condition. There are various

  • Therapeutic options: There are various therapeutic options available which include oral/IV steroids, and immunosuppressive drugs such as cyclophosphamide, tacrolimus, MMF.
  • Procedures such as plasmapheresis are used to remove harmful antibodies from the blood, while dialysis may be necessary for patients with severe kidney dysfunction.
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Gastric Polyps

Management Team

Gastric Polyps

Overview

Gastric polyps are abnormal growths or lesions that develop on the lining of the stomach. While many gastric polyps are benign (non-cancerous), some types can be precancerous or lead to gastric cancer if left untreated. These growths can vary widely in size, shape, and type, and are typically discovered incidentally during procedures like endoscopy.

There are several different types of gastric polyps, each with its own characteristics and potential risk factors. The major types include:

  • Hyperplastic polyps:
    • Hyperplastic polyps are the most common type of gastric polyp and are usually associated with chronic gastritis or inflammation of the stomach lining.
    • These polyps are often benign but can sometimes be large and may cause bleeding or obstruction.
    • Although rare, hyperplastic polyps can become precancerous, especially when they are large or numerous.
  • Fundic gland polyps:
    • Fundic gland polyps are typically small, benign growths found in the upper part of the stomach (the fundus).
    • These polyps are often associated with the use of proton pump inhibitors (PPIs), which are medications that reduce stomach acid production. Long-term use of PPIs can increase the risk of developing fundic gland polyps.
    • Fundic gland polyps are usually asymptomatic, and most do not require treatment unless they cause symptoms or are associated with an underlying condition, such as familial adenomatous polyposis (FAP), a genetic disorder that increases the risk of polyps throughout the body.
  • Adenomatous polyps:
    • Adenomatous polyps are the least common type of gastric polyp but are considered precancerous. They have the potential to transform into gastric cancer over time, so they require careful monitoring and management.
    • These polyps may be larger than other types and are typically associated with chronic atrophic gastritis or H. pylori infection.
    • If an adenomatous polyp is found, especially one with dysplastic changes (abnormal cells), it may need to be removed, as it has a higher risk of malignancy.
  • Inflammatory polyps:
    • Inflammatory polyps are generally benign growths that result from chronic inflammation or injury to the stomach lining, such as from gastritis or peptic ulcers.
    • These polyps are typically small and are not usually associated with cancer. Inflammatory polyps can often resolve on their own with the treatment of the underlying condition.
  • Hamartomatous polyps:
    • Hamartomatous polyps are rare growths that arise from a disorganised growth of normal tissue. They are often associated with genetic conditions such as Peutz-Jeghers syndrome or Juvenile polyposis syndrome, which predispose individuals to developing multiple polyps throughout the gastrointestinal tract, including the stomach.
    • These polyps can be benign but, in some cases, may increase the risk of gastrointestinal cancers.

Most gastric polyps do not cause symptoms, especially if they are small. However, larger polyps or those that cause complications can present with the following symptoms:

  • Abdominal pain or discomfort: Larger polyps, especially those causing obstruction or bleeding, can result in discomfort or pain in the upper abdomen.
  • Bleeding: Polyps, particularly hyperplastic or adenomatous polyps, can cause gastrointestinal bleeding, which may result in:
  • Black, tarry stools (melena) due to digested blood.
  • Vomiting blood (hematemesis), which may appear as bright red or coffee-ground-like material.
  • Nausea and vomiting: If the polyps are large enough to cause partial obstruction of the stomach, nausea and vomiting may occur.
  • Anaemia: Chronic blood loss from gastric polyps can lead to iron-deficiency anaemia, which can present as fatigue, weakness, and pallor.
  • Indigestion: Some individuals may experience indigestion or a feeling of fullness due to polyps, especially if they are large enough to affect stomach function.
  • Loss of appetite or weight loss: In cases where polyps cause significant gastrointestinal issues, a loss of appetite or unintended weight loss may occur.

Gastric polyps are often discovered incidentally when a patient undergoes an upper gastrointestinal endoscopy (EGD) for another condition. The following diagnostic tools may be used:

  • Endoscopy: The primary method for detecting gastric polyps. During an endoscopy, a flexible tube with a camera is inserted into the stomach, allowing doctors to visually identify and assess the size, number, and type of polyps.
  • Biopsy: A small tissue sample may be taken from the polyp to determine whether it is benign or precancerous, especially in the case of adenomatous polyps.
  • Imaging: CT scans or MRI are not typically used to diagnose gastric polyps but may be helpful if there are concerns about complications such as gastric outlet obstruction or perforation.
  • Helicobacter pylori testing: If there is suspicion of H. pylori infection, which is linked to the development of some types of gastric polyps, testing via breath tests, blood tests, or stool tests may be conducted.

The treatment of gastric polyps depends on the type, size, and whether there is a risk of malignancy. Options include:

  • Endoscopic removal: Larger polyps, especially adenomatous polyps or those causing symptoms (e.g., bleeding or obstruction), may be removed via endoscopic polypectomy. This involves using endoscopic instruments to remove the polyp, and it is typically a minimally invasive procedure.
  • Endoscopic removal is also recommended for precancerous polyps to prevent them from developing into gastric cancer.
  • Surgical Intervention: Surgical resection may be necessary if the polyps are too large, if there are multiple polyps, or if there is a concern about cancer that cannot be addressed endoscopically. This is more common in cases of familial adenomatous polyposis (FAP) or other genetic conditions that predispose individuals to multiple polyps.
  • Treatment of underlying conditions: If polyps are associated with an underlying condition such as H. pylori infection or the long-term use of proton pump inhibitors (PPIs), addressing these conditions may help reduce the risk of polyp recurrence or growth.
  • For H. pylori-associated polyps, antibiotic treatment can help eradicate the infection, potentially reducing the number of polyps.
  • Proton pump inhibitors (PPIs): If polyps are related to long-term PPI use, and the polyps are small and asymptomatic, the physician may suggest discontinuing or reducing the use of PPIs. However, this should be done cautiously, as PPIs are important for managing conditions like acid reflux and gastritis.

While gastric polyps cannot always be prevented, there are several strategies that may reduce the risk of developing them or help with early detection:

  • Helicobacter pylori eradication: Treating H. pylori infections can help prevent the development of certain types of gastric polyps, especially those associated with chronic gastritis.
  • Limit use of NSAIDs: Long-term use of NSAIDs can increase the risk of developing gastric polyps, particularly in people with a history of gastritis or ulcers. Taking NSAIDs with food or using alternative pain-relief medications may help reduce the risk.
  • Avoid smoking and excessive alcohol: Smoking and heavy drinking both contribute to inflammation and can increase the risk of developing gastric diseases, including polyps.
  • Regular monitoring: For individuals with genetic conditions like familial adenomatous polyposis (FAP) or Juvenile polyposis syndrome, regular screening with endoscopy is important for early detection and removal of polyps.
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Gastric Ulcer

Management Team

Gastric Ulcer

Overview

Gastric ulcer refers to an open sore or lesion that forms due to the erosion of the stomach's mucosal barrier, which protects it from the acidic environment needed for digestion.

The development of gastric ulcers can be linked to several factors, often involving an imbalance between gastric acid production and the stomach's natural protective mechanisms. The most common factors include:

  • Helicobacter pylori infection: Helicobacter pylori (H. pylori) is one of the most common causes of gastric ulcers. It weakens the protective mucus lining of the stomach, making it more vulnerable to the damaging effects of stomach acid.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): Prolonged NSAID use (e.g., ibuprofen, aspirin) can irritate the stomach lining, increasing the risk of ulcers. These drugs inhibit the production of prostaglandins that help protect the stomach lining from acid. Without adequate prostaglandins, the stomach is more vulnerable to acid damage.
  • Excessive alcohol consumption
  • Smoking
  • Psychological stress
  • Other medical conditions: Chronic liver disease and Zollinger-Ellison syndrome (a condition where tumours in the pancreas or duodenum cause excess acid production) may increase the likelihood of developing gastric ulcers.
  • Genetics
  • Older age

The symptoms of gastric ulcers can vary, and some people may not experience any symptoms at all (asymptomatic ulcers). When symptoms occur, they often include:

  • Abdominal pain: Gnawing pain just below the ribcage is the most common symptom of gastric ulcers.
  • Indigestion (dyspepsia): People with gastric ulcers often experience a sense of fullness, bloating, or discomfort after eating, which can be accompanied by nausea or heartburn.
  • Nausea and vomiting: Ulcers can lead to nausea and, in more severe cases, vomiting.
  • Loss of appetite: This may result from the discomfort caused by eating, which can exacerbate ulcer pain.
  • Unintentional weight loss: This may occur due to a reduced appetite and difficulty eating because of pain.
  • Bloating: This may be caused due to gastric inflammation.
  • Blood in stools or vomit: These are signs of gastrointestinal bleeding, which can occur if the ulcer erodes into a blood vessel.

If gastric ulcers are suspected, doctors may use several diagnostic methods to confirm the diagnosis:

  • Endoscopy (EGD): This is most common diagnostic test for gastric ulcers. It allows the direct observation of the ulcer, assessment of its size, and collection biopsies if needed (e.g., to test for H. pylori infection or to rule out cancer).
  • Helicobacter pylori testing: Various tests, such as breath tests, blood tests, and stool tests can be used to detect H. pylori infection and determine its invasion into the gastric system.
  • X-rays or barium swallow: Although not commonly used, an upper gastrointestinal series (barium swallow) may be performed to detect gastric ulcers. In this technique, the patient swallows a liquid containing barium, which then coats the stomach lining, making ulcers visible on X-ray.
  • CT scan: CT may be used if there is suspicion of complications such as perforation or obstruction.

Key treatment approaches for gastric ulcer include:

  • Medications:
    • Proton pump inhibitors (PPIs): Medications like omeprazole, lansoprazole, or pantoprazole reduce stomach acid production and help the ulcer heal. PPIs are often the first-line treatment for gastric ulcers.
    • Antibiotics (for H. pylori infection): If the ulcer is caused by H. pylori, a combination of antibiotics (e.g., amoxicillin, clarithromycin, metronidazole) is prescribed along with a PPI to eradicate the infection.
    • H2-receptor antagonists: These medications decrease the production of stomach acid.
    • Antacids and antisecretory drugs: Antacids (e.g., calcium carbonate) or sucralfate can help neutralise stomach acid and promote healing.
    • Cytoprotective agents: These agents (e.g., misoprostol) protect the stomach lining and are sometimes used to manage ulcers caused by NSAIDs.
  • Discontinuation of NSAIDs and alcohol: If ulcers are caused by NSAIDs or alcohol, it is important to stop using these substances to allow the ulcer to heal.
  • Surgical intervention: Surgery may be necessary in cases of complications like perforation, severe bleeding, or gastric outlet obstruction.

To reduce the risk of developing gastric ulcers, the following steps may be helpful:

  • Limit NSAID use: Use NSAIDs only when necessary and under the supervision of a doctor, and take them with food to minimise stomach irritation.
  • Avoid smoking and excessive alcohol consumption: Both smoking and alcohol increase stomach acid production and impair healing.
  • H. pylori eradication: If you have a known H. pylori infection, get appropriate treatment to prevent ulcers.
  • Healthy eating: While spicy or acidic foods are not a direct cause of ulcers, eating a balanced, nutritious diet can support overall gastrointestinal health.
  • Stress management: Managing stress through yoga or deep breathing may help reduce the risk of gastritis and ulcers.
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