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Gastric Varices

Management Team

Gastric Varices

Overview

Gastric varices are enlarged veins that develop in the stomach as a result of increased pressure in the portal vein that transports blood from the organs of the digestive system to the liver. These varices are similar to oesophageal varices but are located in the stomach.

Gastric varices can be dangerous because, like oesophageal varices, they can rupture and lead to bleeding, which can be life-threatening.

The primary cause of gastric varices is portal hypertension, which can arise from various conditions that affect the liver and the blood flow through it:

  • Cirrhosis: By extension, it is most common cause of gastric varices.
  • Liver disease: Conditions, such as alcoholic liver disease or hepatitis can damage the liver and lead to the development of portal hypertension, which is the primary cause of varices.
  • Portal vein thrombosis: It can lead to portal hypertension as the blood clot in question can obstruct blood flow, and the portal hypertension further leads to the formation of varices in the stomach and other parts of the digestive tract.
  • Schistosomiasis: This parasitic infection can cause liver damage and portal hypertension, leading to the development of varices, including gastric varices.
  • Budd-Chiari syndrome: This rare condition involves obstruction of the hepatic veins, preventing blood from leaving the liver, which can lead to portal hypertension and variceal formation.
  • Congenital disorders: Rare congenital conditions that affect the liver or portal vein can also lead to the development of gastric varices.

In many cases, gastric varices do not produce symptoms until they bleed; however, when symptoms are noticeable, the following can be observed:

  • Upper abdominal pain: This pain can be dull or sharp and may occur in the region occupied by the stomach, i.e., upper left abdomen.
  • Nausea and vomiting: These are especially common when varices are irritated or bleeding.
  • Vomiting blood (hematemesis): This is a sign of bleeding varices.
  • Black, tarry stools (melena): This can indicate bleeding from the gastric varices, as the blood becomes digested in the stomach.
  • Fatigue: This can be attributed to chronic blood loss or the underlying liver disease.
  • Jaundice: This is associated with liver dysfunction and observed when the varices can be attributed to cirrhosis or severe liver disease.
  • Ascites: Fluid accumulation in the abdomen, commonly seen in cirrhosis, which may worsen with portal hypertension.

Gastric varices are diagnosed through a combination of clinical assessment, imaging, and endoscopy:

  • Endoscopy: Upper gastrointestinal endoscopy (EGD) is the most effective way to diagnose gastric varices. During this procedure, a tube-bound camera inserted through the mouth is used to visualise the stomach lining and check for varices. This method can help assess the size, location, and severity of gastric varices, as well as identify active bleeding or other complications.
  • Imaging:
    • CT scan (computed tomography) or MRI: These can be used to assess liver damage, portal hypertension, and varices.
    • Ultrasound with Doppler: This may help detect portal vein abnormalities, liver cirrhosis, and assess blood flow in the portal venous system.
    • Endoscopic ultrasound (EUS): This modality combining endoscopy with ultrasound, allows high-resolution imaging of the varices and nearby structures.
  • Laboratory tests: Blood tests to assess liver function (e.g., liver enzymes, bilirubin, albumin) and look for signs of anaemia (from bleeding) or other complications of portal hypertension can help diagnose gastric varices.

The management of gastric varices primarily focuses on preventing bleeding, treating active bleeding, and managing the underlying cause (such as cirrhosis). Treatment options include:

Prevention of bleeding:

  • Non-specific beta-blockers: Drugs, like propranolol or nadolol can help decrease blood pressure in the portal pressure and prevent variceal bleeding. These are typically used in patients with known varices but no active bleeding.
  • Endoscopic banding or sclerotherapy:
    • Endoscopic variceal ligation (EVL): Also known as banding, this method is commonly used to treat oesophageal varices and may also be used for gastric varices in some cases. A rubber band is placed around the varix to block blood flow and cause the varix to shrink.
    • Endoscopic sclerotherapy: It involves injecting a sclerosing agent into the varices to cause them to close and stop bleeding.
    • Transjugular intrahepatic portosystemic shunt (TIPS): A TIPS procedure creates a bypass, whereby blood from the poral circulation is diverted to the systemic circulation, thereby reducing portal pressure, which by extension, can prevent variceal bleeding. This is often considered for patients with severe portal hypertension and varices that are difficult to manage with other treatments.
  • Management of active bleeding:
    • Octreotide: A somatostatin analogue, octreotide, can help reduce bleeding by lowering portal pressure and constricting blood vessels.
    • Endoscopic treatment: In cases of active bleeding, endoscopic haemostasis techniques (banding, sclerotherapy, or cauterisation) are used to stop the bleeding.
    • Balloon tamponade: In some cases of massive bleeding, a balloon tamponade may be employed to apply pressure to the bleeding varices to control the haemorrhage temporarily until further interventions can be done.
  • Management of the underlying cause: Treating the underlying cause of portal hypertension, such as cirrhosis or liver disease, is essential. This may involve:
    • Antiviral treatments for hepatitis B or C
    • Alcohol cessation in individuals with alcoholic liver disease
    • Liver transplant for end-stage liver disease with severe portal hypertension and varices that cannot be controlled
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Gastritis

Management Team

Gastritis

Overview

Gastritis is a condition wherein the inner layer of the stomach wall (gastric lining) that secretes key molecules required for digestion gets inflamed. This inflammation can cause symptoms, such as pain, nausea (sensation of vomiting), and indigestion, and in severe cases, it may also damage the stomach lining, potentially leading to ulcers, bleeding, or even an increased risk of stomach cancer.

Broadly speaking, gastritis is of the following three types:

  • Acute gastritis: It refers to the sudden inflammation of the gastric lining that is usually caused by irritants, such as alcohol or infection.
  • Chronic gastritis: It refers to the persistent (long-term) inflammation that is caused by persistent bacterial infection (particularly Helicobacter pylori), prolonged use of certain medications, or autoimmune conditions.
  • Erosive gastritis: This is a more severe form of gastritis wherein the stomach lining develops erosions or ulcers.

Gastritis has various causes; these have been enumerated below.

  • Infection:
    • Bacterial infections: Helicobacter pylori (H. pylori) is the leading cause of gastritis. It can damage the protective lining of the stomach, leading to inflammation. It is known to cause both acute and chronic gastritis and is associated with the occurrence of peptic ulcers as well as gastric cancer.
    • Oher infections: Infections caused by other entities, such as viruses, fungi, or parasites can also cause inflammation, though they are less common.
  • Medications:
    • Nonsteroidal anti-inflammatory drugs (NSAIDs): Chronic (prolonged and persistent) use of NSAIDs like ibuprofen and aspirin is particularly problematic as they can irritate the stomach lining, leading to gastritis. These are linked to all three types of gastritis.
    • Corticosteroids: Medications like corticosteroids that reduce stomach acid can also contribute to the development of gastritis.
  • Alcohol abuse: Alcohol acts as an irritant and can wear away the stomach lining, leading to all three types of gastritis. Alcohol also increases the risk of stomach bleeding.
  • Bile reflux: When bile produced by the liver backflows into the stomach (bile reflux), the stomach lining gets inflamed, leading to gastritis. This condition is associated with both chronic and acute gastritis.
  • Autoimmune reactions: Long-term (chronic) is caused when the body’s immune surveillance mechanism erroneously targets cells lining the stomach.
  • Stress: Physical stress (due to surgery, injury, or illness) or emotional stress may exacerbate gastritis symptoms or contribute to its development, though it is not usually the primary cause.
  • Other causes:
    • Smoking: Nicotine, the key component of tobacco, can increase stomach acid production even in the absence of food, resulting in higher acidity. Excess acid can irritate the stomach lining, thereby causing gastritis.
    • Dietary factors: Very spicy foods or large meals can irritate the stomach lining, especially when it is already inflamed, thereby causing gastritis.

Common symptoms of gastritis have been described below.

  • Upper abdominal pain: The key features of gastritis, i.e., increased gastric acid production, irritation, inflammation, and damaged gastric lining result in a burning or gnawing pain in upper abdomen, a place where the stomach is situated.
  • Nausea (feeling to vomit) and vomiting: Excess acid in the stomach causes the stomach to send signals to the brain to induce nausea and vomiting (possibly with blood in severe cases).
  • Indigestion (dyspepsia): Irritation and inflammation of the stomach lining lead to an imbalance in stomach acid production and delayed gastric emptying, which contributes to symptoms of indigestion, like pain, bloating, feeling full, and nausea.
  • Loss of appetite: The combination of irritation, inflammation, pain, acidity, nausea, and bloating might result in loss of appetite in some individuals.
  • Black, tarry stools: Gastrointestinal bleeding due to excess gastric acid production might result in black tarry stools, which require immediate medical attention.
  • Vomiting blood: In severe cases of gastritis due to excess gastric production and eroded gastric lining the stomach lining may bleed, leading to blood in the vomit.

Gastritis involves several tests and examinations; these include:

  • Physical examination: Palpation (physical examination) might reveal bloating and tenderness in the abdomen, which along with medical history might indicate gastritis.
  • Endoscopy (EGD): EGD can help identify inflammation, ulcers, or other abnormalities in the stomach.
  • Biopsy: Tissue sample collected during endoscopy can help detect infections (e.g., H. pylori), autoimmune gastritis, or gastric cancer.
  • Blood tests: Blood tests may help detect signs of anaemia (a sign of bleeding gastritis) or infections (e.g., H. pylori).
  • Stool test: This test can provide information as to whether there is gastrointestinal bleeding (blood in the stool) or infection (pathogen in stool).
  • Urea breath test: This test can detect H. pylori infection by measuring certain the carbon dioxide produced by the bacteria upon breaking down urea.

Common approaches to treat gastritis include:

  • Medications:
    • Antibiotics: If H. pylori is the causative agent, antibiotics (such as clarithromycin, amoxicillin, or metronidazole) are prescribed to eradicate the bacteria.
    • Proton pump inhibitors (PPIs): Drugs, like omeprazole, lansoprazole, and esomeprazole decrease the amount of gastric acid produced, thereby providing relief in gastritis.
    • H2-receptor antagonists: Similar to PPIs, drugs like famotidine and ranitidine also decrease the amount of stomach acid produced and can provide relief in gastritis.
    • Antacids: Prescription-free medications, like calcium carbonate and magnesium hydroxide can help neutralise stomach acid, thereby providing relief from discomfort.
    • Cytoprotective agents: Medications like sucralfate may be used to help protect the stomach lining from further irritation.
    • Antiemetics: If nausea is a significant symptom, anti-nausea medications (like ondansetron) may be prescribed.
  • Lifestyle modifications:
    • Avoiding alcohol and NSAIDs: Limiting alcohol consumption and avoiding drugs like ibuprofen or aspirin (unless otherwise directed by your doctor) can prevent further irritation of the stomach lining.
    • Eating smaller meals: Consuming smaller meals though, more frequently can help reduce stomach irritation.
    • Avoiding spicy, acidic, and fatty foods: Spicy, acidic, or fat-rich foods can exacerbate gastritis, therefore a bland diet, with foods like rice, oatmeal, and bananas, may be recommended during flare-ups.
    • Managing stress: Techniques for managing stress, such as deep breathing, meditation, yoga, and exercise can help reduce gastritis symptoms, especially in individuals with stress-related gastritis.
  • Endoscopic treatment: If there is significant bleeding or ulcers, endoscopic procedures may be needed to stop the bleeding or remove damaged tissue.
  • Surgery: In rare cases, if gastritis causes severe complications like perforation (a hole in the stomach lining), surgical intervention may be necessary.

Please consult a healthcare professional if you observe any symptoms of gastritis. Seek immediate medical attention if you experience any of the following:

  • Persistent or severe abdominal pain
  • Vomiting blood
  • Black, tarry stools, which can indicate gastrointestinal bleeding

Gastritis can be prevented by taking the following steps:

  • Limiting alcohol consumption: Avoid excessive drinking, which can irritate the stomach lining.
  • Using NSAIDs cautiously: Take NSAIDs only as prescribed, and try to avoid long-term use. If you need pain relief, consider alternatives like acetaminophen.
  • Washing hands regularly: This can help prevent H. pylori infection, especially in areas with poor sanitation.
  • Avoiding spicy and irritating foods: Avoid foods that can aggravate an already inflamed stomach lining.
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Gas and Bloating

Management Team

Gas and Bloating

Overview

Gas and bloating are common gastrointestinal complaints that can cause discomfort and inconvenience.

  • Swallowing air: commonly occurs if a person eats or drinks too quickly, chews gum, or smokes.
  • Improper digestive process: if the gut microbiota is not balanced, breakdown of certain food by the gut bacteria produces gas (e.g., beans, lentils, carbonated drinks).
  • Food intolerances/allergies.
  • Excessive mental tension: Anxiety or depression.
  • Constipation
  • Overeating
  • Fluid retention
  • Digestive disorders: conditions such as irritable bowel syndrome (IBS), GERD, or infections can cause bloating.
  • Certain type of food: High-fibre food, cruciferous vegetables (broccoli and cauliflower), and carbonated beverages can contribute to bloating.

  • Abdominal discomfort or pain
  • Visible swelling or distention of the abdomen
  • Excessive passing of gas (belching or flatulence)
  • Feeling of fullness or pressure in the abdomen

  • Medical history: Your medical history can be reviewed by your gastroenterologist for evaluating your symptoms, diet, and lifestyle.
  • Physical examination.
  • Tests: potential tests might include blood tests, breath tests (for lactose intolerance or bacterial overgrowth), or imaging studies.

  • Lifestyle modifications:
    • Eating slowly and chewing the food thoroughly.
    • Avoiding carbonated drinks and chewing gum.
    • Identifying and avoiding trigger foods.
    • Keeping your mind calm and practicing techniques to keep mental peace.

A lifestyle assessment may help identifying stressors that contribute to symptoms.

  • Diet adjustments:
    • Limit raw food or high-fibre foods, especially if they tend to cause excessive gas or discomfort.
    • Avoid known irritants (e.g., dairy, gluten) if intolerant.
    • Incorporate natural probiotics to promote healthy gut flora (home-made yoghurt or buttermilk and fresh fruits)
  • Medications:
    • Simethicone/simethicone containing digestive enzymes: these are available as an over-the-counter remedy or prescribed by your doctor to relieve bloating and discomfort.
    • Lactase supplements: Those with lactose intolerance can be prescribed lactase supplements.
    • Antacids: antacids help neutralise stomach acid and relieve indigestion and heartburn.
    • Laxatives: To relieve constipation.

Seek medical advice if you experience persistent symptoms of severe abdominal pain, persistent bloating or gas, unintentional weight loss associated with bloating and other GI symptoms, recent changes in bowel habits (like diarrhoea or constipation).

Consulting a healthcare professional is recommended for personalised diagnosis and treatment.

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Gastroesophageal Reflux Disease (GERD)

Management Team

Gastroesophageal Reflux Disease (GERD)

Overview

Gastroesophageal reflux disease (GERD) is a condition where stomach acid or occasionally stomach contents flows back upwards into the food pipe or oesophagus. This can irritate the lining of the oesophagus and lead to various symptoms and complications.

  • Lower oesophageal sphincter (LES) dysfunction: The LES acts as a one-way valve allowing ingested food to go down into the stomach but prevents stomach acid from coming up. A weakened LES can allow stomach contents to reflux upwards.
  • Hiatus hernia: This occurs when the LES is loose and part of the stomach moves up into the chest.
  • Obesity
  • Pregnancy
  • Improper diet and lifestyle: Irregular food timing, fast pace of eating, sleeping immediately after a heavy meal, certain foods such as spicy and fatty food, caffeine, alcohol, and smoking or tobacco chewing can trigger symptoms of GERD.

  • Heartburn (burning sensation in the chest)
  • Regurgitation of food or sour liquid
  • Difficulty swallowing (dysphagia)
  • Chronic dry cough
  • Asthma or worsening of asthma symptoms
  • Recurrent hoarseness or soreness of throat
  • Sensation of a lump in the throat

  • Review of symptoms and medical history: Taken by your gastroenterologist.
  • Physical examination: Examination of your throat and abdomen for any signs of GERD by the doctor.
  • Endoscopy: Upper GI endoscopy is used to make a proper diagnosis of GERD and its complications. In this procedure the gastroenterologist looks inside your food pipe and stomach using a thin, flexible telescope called an endoscope.
  • Oesophageal pH monitoring: This test enables exact diagnosis of GERD.
  • Oesophageal manometry: This test assesses the muscular contractions of the oesophagus.

  • Lifestyle changes: weight loss, eating smaller meals, conducting a lifestyle assessment, avoiding trigger foods, and not lying down after meals.
  • Medications:
    • Antacids: Antacids can be used to neutralise the stomach acid.
    • H2-receptor antagonists: Help reduce acid production.
    • Proton pump inhibitors: These also reduce acid production and are stronger than the H2- receptor antagonists in their action.
  • Advanced endoscopic procedure: Procedures such as endoscopic anti-reflux procedure can be performed by your gastroenterologist. This procedure remodels the disturbed lower oesophageal sphincter making it tight without any surgery or external incision.
  • Surgery: In severe cases, surgical options like fundoplication may be considered for acid reflux treatment.

  • Maintain a healthy weight.
  • Follow a balanced diet and avoid trigger foods.
  • Avoid having heavy and late dinner.
  • Take a walk after dinner.
  • Avoid smoking/chewing tobacco and limit alcohol intake.
  • Elevate the head of the bed if symptoms occur at night.

If you suspect you have GERD or are experiencing persistent symptoms, it is important to consult a healthcare professional for proper diagnosis and treatment.

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Genetically Inherited Diseases

Management Team

Genetically Inherited Diseases

Overview

Genetic disorders are illnesses caused by alterations in a person's DNA. These anomalies may arise spontaneously as a result of alterations in the DNA sequences or they may be passed down from one or both parents. As the name implies Inherited disorders are genetic illnesses passed onto their offspring via their parents' genes.

  • Genetic disorders can affect any organ system and people from any age group. 
  • Genetic disorders can affect a person's appearance, how their organs function, their metabolism, and even their susceptibility to certain diseases.

  • X-linked disorders: occur on the X chromosome
  • Autosomal dominant: only one copy of the abnormal gene is needed for the disorder to manifest
  • Autosomal recessive: requiring two copies of the abnormal gene
  • Mitochondrial disorders: affecting the energy-producing structures within cells

Genetic disorders can have a variety of causes:

  • Changes or mutations in a single gene
  • Complex interactions between numerous genes and environmental factors
  • Environmental factors such as exposure to toxins, radiation, or specific medications, can impact the occurrence of genetic disorders

Every disorder has a different set of symptoms and individual inheritance patterns. Accordingly, methods for treating these disorders may vary. 

  • Medical Assessment: includes a thorough assessment of a person's medical history, physical examination, and family history.
  • In some cases, precision genetic testing may be suggested

These tests might be performed during pregnancy, after childbirth (neonatal and paediatric testing), or during adulthood, depending on the suspected disorder and the particular circumstance.

  • Hereditary cancers
  • Hereditary cardiac conditions
  • Chromosomal abnormalities which cause birth defects, intellectual disabilities, and/or reproductive problems
  • Inherited metabolic disorders
  • Single gene disorders, such as:
    • Thalassaemia
    • Muscular dystrophy
    • Huntington's disease
    • Sickle cell disease:
  • Birth defects associated with the involvement of a genetic component
    • Neural tube defects
    • Cleft lip
    • Cleft palate
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Genu Varum (Bowed Legs)

Management Team

Genu Varum (Bowed Legs)

Overview

Genu varum is a paediatric orthopaedic condition involving leg deformity, which is also known as bowed legs. It is a skeletal disorder where the legs curve outward at the knees while the ankles are close together.

  • Usually symptomless, apart from cosmetic concerns.
  • Occasionally, in children, difficulty in walking and or pain in the outer part of the knees.

  • Bowing of the knees is normal till the age of 2 years.
  • Vitamin D deficiency.
  • Bone growth disorders like rickets, Blount disease, and osteogenesis imperfecta.
  • Genetic disorders, such as Carpenter syndrome.

  • Physical examination where the patient stands with both legs parallel to each other and both ankles together and the distance between both knees and ankles is measured.
  • A full-length radiograph (X-ray) of both legs (scanogram) to measure the extent of varus (deformity in the knees).
  • Radiograph of the knee joints at two different angles (anteroposterior and lateral views) to detect abnormality of the growth plates (ends of the bones in the knee joint).
  • Computed tomography (CT) for treatment planning.

Non-surgical treatment

Non-surgical treatment is the primary line of management. It includes:

  • Observation in cases of physiological (natural) varus.
  • Nutritional correction for vitamin D deficiency.
  • Bracing for minimal deformity.

Surgical treatment

Surgery is indicated in the advanced stage of the disease and when non-surgical management fails. Corrective osteotomy is required for severe deformities.

It involves placing small plates/screws to restrict the growth on the outer side of the knees, restricting the deformity. The implants are usually removed once the child achieves complete growth. However, growth may be restricted when the screw penetrates the growing region of the bone.

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Ganglion Cyst

Management Team

Ganglion Cyst

Overview

Ganglion cysts are small fluid-filled swellings usually over the tendon sheaths. They most commonly affect the wrist, ankle, or feet. The cause of ganglion cysts is unknown.

  • The patient usually presents with a soft painless swelling over the dorsum of the wrist joint (most common site).  
  • Dull aching pain with terminal movements at the wrist joint.
  • Rarely, the swelling compresses the underlying nerves, leading to tingling, numbness, and occasionally muscle weakness.

  • Women are more commonly affected than men.
  • High activity at young age (15–40 years).
  • Excessive friction and repetitive stress (like performing gymnastics).

  • Physical examination.
  • Radiography (X-ray) to assess the condition of the underlying joint and identify old pathologies.
  • Ultrasonography or magnetic resonance imaging (MRI) to rule out other causes of swelling and identify the exact anatomy, location, and extent of the cyst to plan treatment.

Non-surgical treatment

Conservative management is the initial treatment of choice. It includes:

  • Observation, if there is no pain.
  • Splints, such as a wrist brace to help immobilise the joint, alleviate pain, and decrease swelling.
  • Aspiration is recommended for large swellings affecting daily activities.

Surgical treatment

Surgical excision is recommended for patients for whom conservative management has failed. The surgical options are as follows:

  • Open excision to allow access to the complete cyst including the stalk and the wall. However, the chances of cyst recurrence can be up to 40%. A splint is advised for approximately 2 weeks after the surgery following which gradual movements are allowed.
  • Excision through arthroscopy procedure involves minimal incisions and less soft tissue damage and allows enhanced visualisation of the joint (most commonly the scapho-lunate joint) without jeopardising the articular cartilage. However, this technique requires extensive expertise.
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