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Liver Cirrhosis

Management Team

Liver Cirrhosis

Overview

Cirrhosis is characterised by the progressive replacement of healthy liver tissue with the scar tissue (fibrosis), which disrupts key liver functions, such as detoxification, bile secretion, clotting factor production, and nutrient storage in addition to impairing normal blood flow to the liver, ultimately resulting in life-threatening complications. Importantly, the regeneration capacity of the liver is also compromised by the scar tissue formed in cirrhosis; therefore, in advanced stages of the disease, the liver is unable to regenerate and start functioning properly, i.e., permanent loss of function. Thus, cirrhosis is the final stage of chronic liver disease. Cirrhosis can be attributed to various factors, including persistent inflammation of the liver, fatty liver disease (N/AFLD), viral hepatitis, and certain inherited conditions.

Cirrhosis can be attributed to the following factors:

  • Excessive and prolonged (chronic) alcohol consumption
  • Hepatitis:
    • Chronic viral hepatitis: Viral infections result in significant liver damage as viral clearance involves killing of the cells harbouring the virus. Especially, Hepatitis B and C viruses can cause more liver damage (compared to other Hepatitis viruses) as they are more persistent (chronic), causing chronic liver inflammation that progressively leads to scarring, eventually culminating in cirrhosis.
    • Autoimmune hepatitis: Killing of self-liver cells by the immune surveillance machinery causes chronic inflammation (a hepatitis hallmark), which then progresses to scarring (fibrosis), and eventually cirrhosis.
  • Fatty liver: Accumulation of fat in the liver results in inflammation, which over time induces scarring, and ultimately leads to cirrhosis.
  • Genetic disorders: Certain inherited conditions can lead to cirrhosis; these include:
    • Wilson’s disease (copper overload)
    • Haemochromatosis (iron overload)
    • Alpha-1 antitrypsin deficiency (a disorder that can cause liver damage).
  • Biliary diseases: Diseases of the biliary system, such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) cause bile duct damage, resulting in bile buildup in the liver, which causes inflammation that ultimately culminates in scarring and cirrhosis.
  • Medications and toxins: Long-term use of certain medications (e.g., methotrexate, isoniazid) and exposure to industrial toxins or chemicals can cause liver damage and cirrhosis.
  • Chronic heart failure: Severe, long-standing heart failure can cause liver congestion, a condition where blood pools in the liver and associated blood vessels, this causes liver tissues to become stressed due to lack of oxygen and bile acid accumulation, ultimately leading to liver damage and cirrhosis (cardiac cirrhosis).
  • Other causes: Conditions like gallstones and hepatocellular carcinoma (liver cancer) can also contribute to cirrhosis.

Cirrhosis, in its early stages may be asymptomatic (no obvious symptoms); however, as it progresses, the symptoms become more pronounced and may include:

  • Fatigue
  • Jaundice
  • Abdominal pain
  • Swelling (oedema
  • Nausea and loss of appetite
  • Easy bruising or bleeding
  • Spider angiomas: These are small, red, spider-like blood vessels visible under the skin, often on the chest and upper body.
  • Hepatic encephalopathy: The buildup of toxins like ammonia in the blood owing to the impaired detoxification function of the liver might result in hepatic encephalopathy, which manifests as confusion, altered mental status, forgetfulness, and even coma.
  • Pruritus (itching)
  • Dark urine and pale stools
  • Impaired clotting

  • Physical examination: Cirrhosis can be diagnosed by looking for signs, such as jaundice, ascites, an enlarged liver (hepatomegaly), or an enlarged spleen (splenomegaly) in clinical examination.
  • Blood tests:
    • Liver function tests: To evaluate the levels of liver enzymes (ALT, AST), bilirubin, and albumin, and determine the prothrombin time (clotting function)
    • Complete blood count (CBC): To check for anaemia, low platelet counts, or signs of bleeding
    • Ammonia level assessment: To detect hepatic encephalopathy
  • Imaging:
    • Ultrasound: To detect liver size and shape, and signs of cirrhosis, such as nodularity and ascites
    • CT: To detect complications like liver cancer
    • MRI: To assess liver fibrosis and portal hypertension
  • Elastography (FibroScan): To assess the degree of fibrosis based on measurement of liver stiffness
  • Liver biopsy: This may be performed to assess the degree of fibrosis and confirm cirrhosis. However, liver biopsy is usually reserved for cases where other diagnostic methods are inconclusive.

The treatment of cirrhosis is aimed at managing symptoms, preventing complications, and addressing the underlying cause. While cirrhosis is not reversible, interventions can slow the progression and improve quality of life.

  • Treating the underlying cause:
    • Alcohol abstinence: In case of alcohol abuse-induced cirrhosis, stopping alcohol consumption is crucial in preventing further liver damage.
    • Antiviral therapy: In case of viral hepatitis-induced cirrhosis, antiviral medications can reduce viral load and prevent further liver damage.
    • Weight management: For patients with NAFLD or NASH, weight loss through diet and exercise is important for managing liver fat and improving liver function.
    • Medications:
      1. Antiviral medications: These are used to manage viral hepatitis.
      2. Immunosuppressive drugs: These are used to manage autoimmune hepatitis.
  • Managing complicated cirrhosis:
    • Beta-blockers: These medications (e.g., propranolol, nadolol) reduce portal pressure, thereby helping manage portal hypertension-associated complicated cirrhosis.
    • Transjugular intrahepatic portosystemic shunt (TIPS): It is generally used for complicated cases of cirrhosis where portal hypertension and associated complications are difficult to manage. TIPS involves creating a shunt between the portal and hepatic veins, which diverts blood flow from the portal circulation to systemic (whole body) circulation, thereby reducing the pressure in the portal system. Thus, TIPS can provide relief for portal hypertension-associated complications of cirrhosis.
  • Managing symptoms:
    • Medications:
      1. Diuretics: These are used to decrease fluid accumulation in tissues (ascites).
      2. Lactulose: It is used to manage hepatic encephalopathy by reducing the ammonia levels.
  • Liver transplant: This might be necessary in cases of advanced cirrhosis with liver failure.

  • Avoiding excessive alcohol consumption.
  • Vaccination against hepatitis B and C
  • Employing safe practices to prevent hepatitis transmission (e.g., avoid sharing needles)
  • Weight management and exercise to prevent fatty liver disease
  • Regular screenings for individuals with chronic liver disease or a family history of liver conditions
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Living Donor Kidney Transplant

Management Team

Living Donor Kidney Transplant

Overview

This is a surgical procedure in which a kidney from a living donor and transplanted into a recipient who is experiencing kidney failure. As one kidney is adequate to sustain a healthy life, the donor can go on to live a healthy life even after the kidney donation.

Before undergoing a living donor kidney transplant, the transplant team evaluates your overall health, verifies the donor’s health, and ensures the kidney is a suitable match for you. Living donor kidney transplants provide some benefits as compared to decreased donor kidney transplants, such as:

  • Shorter waiting time: The database and waitlist for deceased donor kidneys is typically maintained nationally. The health of the patient who requires a kidney may decline while waiting for a suitable kidney to become available
  • Can help avoid dialysis: If the patient has not yet started dialysis, transplantation can help avoid it
  • Better survival rates: Patient survival rates are usually higher after kidney transplantation
  • Scheduled transplant surgery: Deceased donor kidneys have a short window during which they must be transplanted, leading to unscheduled and urgent surgery. On the other hand, with a living donor, the transplant can be planned and scheduled ahead of time.

During a living donor kidney transplant, the donor kidney is positioned within the patient’s lower abdomen. Its blood vessels are connected to those in the lower abdomen or above one of the legs. The ureter, a tube that carries urine, is then attached from the new kidney to the bladder to enable urine flow. Typically, the patient’s non-functioning kidneys are left within the body.

  • The surgery is followed by a hospital stay of a few days to a week
  • An immune-suppressing medication regimen to prevent the immune system from rejecting the kidney is prescribed
  • Additionally, antibacterial, antiviral, and antifungal medicines are provided to prevent an infection
  • The medication regimen needs to be followed carefully because skipping them for even a short period can cause the body to reject the kidney
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Laser Prostatectomy

Management Team

Laser Prostatectomy

Overview

This is a laser-enabled surgery used to treat moderate-to-severe symptoms caused by benign prostate enlargement or hyperplasia (BPE or BPH). As the prostate surrounds the urethra, the tube through which urine exits the body, an enlarged prostate restricts the flow of urine from the bladder. BPE/H is a non-cancerous enlargement of the prostate gland.

Laser surgery tends to be non-invasive or minimally invasive. Moreover, unlike pharmaceutical treatments, surgical treatments offer immediate improvements in symptoms. Laser surgery also provides many benefits over other surgical methods of treating BPE/H, such as:

  • Lower risk of bleeding: This makes it suitable for people who take blood thinners or who have bleeding disorders that cause abnormal clotting
  • Shorter hospital stay/outpatient procedure: As the surgery and recovery are quick, it can be performed on an outpatient basis or requiring only an overnight hospital stay
  • Quicker recovery: Recovery following laser surgery is generally compared to open surgery or trans-urethral resection of the prostate
  • Reduced need for catheter: Unlike other surgical treatments for BPE/H, which often require a catheter (tube) to drain urine from the bladder after surgery for extended period, laser surgery typically necessitates a catheter for less than 24 hours.

This is a surgical procedure during which a scope is gently inserted through the penile tip into the urethral opening. As the laser is carefully passed through the scope it reduces or shrinks excess tissue from the prostate and removes the restrictions on urine flow. The different types of laser prostate surgery include:

  • Green light laser vaporisation: The urinary tract is enlarged by melting away/vaporising the excess tissue of the prostate. Mild-to-moderate BPE/H can be treated using this technique
  • Holmium laser enucleation (HoLEP): Here, the excess prostate tissue restricting the urethra is cut and removed using a laser. Following this process, another instrument slices the prostate tissue into small pieces, which can then easily removed. HoLEP is typically used to treat severely enlarged prostates.
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Leukoplakia

Management Team

Leukoplakia

Overview

Leukoplakia refers to the growth of white patches or plaques that develop on the mucous membranes inside the oral cavity, including the tongue, cheeks, and gums. The patches are often thickened, and they typically cannot be wiped off, a feature that distinguishes them from other types of white lesions in the mouth, such as those caused by oral thrush. Leukoplakia is considered a precancerous condition as leukoplakia lesions have the potential to develop into oral cancer; however, not all lesions become cancerous.

  • Tobacco use: Smoking (even smokeless tobacco) is the most well-known risk factor for leukoplakia. Constant irritation caused by tobacco products can lead to the formation of these white patches.
  • Alcohol consumption: Heavy drinking, especially in combination with tobacco use, increases the risk of leukoplakia and may also increase the risk of malignant transformation.
  • Chronic irritation or trauma: Regular irritation from ill-fitting dentures, sharp edges of teeth, or other mechanical factors can contribute to the development of leukoplakia.
  • Human papillomavirus (HPV): Some studies suggest that certain strains of the human papillomavirus (HPV), especially HPV-16, may be involved in leukoplakia development, particularly in the context of oral cancers.
  • Weakened immune system: Conditions like HIV/AIDS or immunosuppressive treatments (e.g., chemotherapy, organ transplant drugs) can increase susceptibility to leukoplakia.
  • Nutritional deficiencies: Deficiencies of vitamins, particularly vitamin A and B12, may contribute to leukoplakia.
  • Age and gender: Leukoplakia is more common in the elderly or middle-aged individuals. Further, men are at a higher risk of being affected by this condition than women.
  • Other factors: Certain chronic conditions, such as lichen planus (a disease that affects the skin and mucous membranes), can also predispose individuals to leukoplakia.

  • White patches: The hallmark of leukoplakia is the appearance of thick, white or greyish patches in the mouth. These patches may be slightly raised or flat and cannot be wiped away.
  • Rough texture: These patches are often thick and rough in texture. They may be irregular in shape.
  • Burning sensation: Though most people with leukoplakia do not experience pain or other symptoms, some individuals may feel a burning sensation or discomfort.
  • Ulceration: In some cases, leukoplakia patches may appear red, ulcerated, or indurated (hardened), which may suggest dysplasia (abnormal cell growth) or early stages of cancer.

  • Visual examination: The mouth and the lesions are visually inspected to look for signs, such as changes in texture, size, or colour, which may indicate more severe issues.
  • Biopsy: This may be recommended for persistent or suspicious lesions to determine whether the lesion/patch is dysplastic (associated with abnormal cell growth) or cancerous.
  • Other tests: Depending on the clinical presentation, i.e., the features and duration of lesion presentation, additional tests (e.g., imaging or HPV testing) may be recommended.

Treatment for leukoplakia is usually focused on addressing the underlying causes, managing symptoms, and monitoring the condition for signs of malignant transformation.

  • Eliminating irritation:
    • Abstinence from smoking and alcohol: One of the most important steps is to quit tobacco use and reduce alcohol consumption, as both are major risk factors for leukoplakia and oral cancer.
    • Address chronic irritation: If ill-fitting dentures, rough dental fillings, or sharp teeth are causing the irritation, they should be adjusted or repaired.
  • Surgical treatment:
    • Surgical removal of lesions: In some cases, particularly if the leukoplakia lesions are large, persistent, or show signs of dysplasia, surgical removal may be necessary.
  • Medications:
    • Topical steroids: In cases where there is significant inflammation or discomfort, topical steroids (like corticosteroid ointments) may be prescribed to reduce irritation and inflammation.
  • Cryotherapy: This technique can be used to remove the patches; it involves freezing the leukoplakia lesion(s) with liquid nitrogen.
  • Laser treatment: Lasers can be used to remove the patches or reduce the size of the lesions, especially in cases of localised leukoplakia.
  • Nutrient supplementation: If leukoplakia is linked to a deficiency (e.g., vitamin A or B12), nutritional supplementation may be recommended.

Consult a healthcare professional, preferably a dentist if you notice any white patches, unusual growth(s), or persistent sores in your mouth.

  • Quit smoking and tobacco use: This is most effective for reducing leukoplakia risk.
  • Limiting alcohol consumption: This can also decrease the risk of leukoplakia, especially when combined with cessation of smoking.
  • Regular dental checkups: These can help detect early signs of leukoplakia and other oral conditions.
  • Healthy diet: This may help decrease leukoplakia risk, particularly if nutritional deficiencies are a contributing factor.
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Loss of Taste and Burning Sensation in the Mouth

Management Team

Loss of Taste and Burning Sensation in the Mouth

Overview

Loss of taste and a burning sensation in the mouth can be caused by a variety of factors. The possible causes are as follows:

Infections

  • Viral infections (COVID-19 or herpes)
  • Fungal infection (oral thrush)

Nutritional deficiencies

Vitamin deficiencies, especially vitamin B complex, zinc, and iron

Side effects of certain medications

Certain medications can affect taste and cause mouth irritation

Allergies

Allergic reactions to specific foods or environmental factors can cause burning sensations.

Oral health issues

Gum diseases, tooth infections, or oral lesions can cause burning sensation in the mouth.

Neurological conditions

Certain neurological disorders like Alzheimer’s, Parkinson’s, multiple sclerosis may alter taste perception

  • Maintain good oral hygiene
    Rinse your mouth with water after every meal and brush and floss your teeth regularly to prevent infections and improve oral health.
  • Stay hydrated
    Drink plenty of water to relieve dryness in the mouth.
  • Have a nutritious diet
    Ensure a balanced diet rich in essential vitamins and minerals.
  • Avoid mouth irritants
    Avoid spicy, acidic, or overly hot foods that may exacerbate burning sensations. Change your toothpaste if it causes mouth irritation and burning. Avoid smoking or chewing tobacco, which can cause further irritation of the lining of the mouth.

Seek prompt medical attention if the burning sensation in your mouth persists despite using simple remedies, or if accompanied by severe symptoms such as swelling and difficulty breathing; or fever.

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Loose/Mobile Teeth

Management Team

Loose/Mobile Teeth

Overview

A tooth that sits loosely within its socket and wiggles is called a mobile tooth. As a child, having loose teeth is a part of development of dentition. However, the occurrence of mobile teeth in adults is never typical, and almost always, indicative of an underlying condition (disease or trauma).

In children, once the permanent (adult) teeth begin to break through the gums, the primary (baby/milk) teeth loosen and eventually, fall out. The factors causing loose teeth in adults include:

  • Periodontal (gum) disease. Periodontitis causes the degradation of the supporting ligaments, tissues, and bones that surround the teeth; globally, among adults, periodontitis is the most prominent cause of loose teeth (and tooth loss).
  • Dental trauma: Dental injuries, such as those caused by sport-related or vehicular accidents, may result in one or more teeth becoming mobile.
  • Teeth grinding (bruxism): Over time, constant tooth clenching or grinding can cause tooth mobility.
  • Pregnancy: Pregnancy-induced surges in the progesterone and oestrogen levels may cause the tissues that hold the teeth in place to loosen (albeit temporarily), a condition termed as pregnancy gingivitis. Usually, in women with this condition, the symptoms disappear after childbirth.

Apart from feeling strange, especially during common oral activities, such as chewing, eating, brushing, or flossing, wobbly teeth may be associated with the following symptoms:

  • Red, tender, bleeding, and/or swollen gums
  • Receding gums, i.e., when the gums wear or pull away, exposing the roots.
  • Tooth discoloration

Eventually, loose tooth may cause:

  • Difficulties with biting and chewing.
  • Excess contact and pressure on the neighbouring teeth.

A loose or mobile tooth can be easily identified as it can be felt with the tongue or finger. Moreover, how the upper teeth sit on the lower teeth may seem different than usual.

During a dental examination, the cause of loose teeth can be ascertained and accordingly, appropriate treatment plans may be recommended.

In general, regular dental examination and cleaning procedures are recommended (often, once every 6 months). However, if patients are prone to developing cavities or gum disease, more frequent visits to the dentist are recommended.

If patients develop loose teeth between visits, they are advised to schedule additional appointments with the dentist, who can begin treatment immediately to reduce the risk of further complications.

The severity and cause of mobile teeth determine the treatment method recommended by the dentist.

  • Treatment for trauma-induced formation of loose teeth:
    • Bite adjustment: A minute amount of enamel is scraped off from the loose and opposing tooth to alleviate the excess pressure from the bite; this helps promote the healing of the wobbly tooth.
    • Mouth guard: In patients with bruxism, this oral appliance shields the teeth from excessive damage and/or pressure.
    • Splinting: In cases where the loose tooth has not yet been pulled away from the gums, two neighbouring teeth are bonded together, so that the loose tooth has additional support and its movement is prevented during healing.
  • Gum disease-induced tooth mobility: The following surgical treatments are recommended:
    • Tooth scaling and root planing
    • Osseous surgery (flap or pocket reduction surgery): A procedure involving the thorough cleaning of the roots of the teeth to clear the bacterial infection, removal of infected tissues, and if necessary, reshaping the bones surrounding the teeth.
    • Application of dental bone and/or gum grafts

Sometimes, when a loose tooth is beyond saving, the dentist is likely to recommend tooth removal, followed by the application of a dental bridge or implant as a replacement for the extracted tooth.

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Lumbar Discectomy

Management Team

Lumbar Discectomy

Overview

Lumbar discectomy is a surgical procedure done for the lumbar spine, wherein a part of the herniated intervertebral disc is removed to relieve pressure symptoms over the nerve root.

  • Sciatica, slip disc, herniated nucleus pulposus (HNP), and disc prolapse are all synonyms for similar conditions. 
  • Heavy weightlifting, heavy labour activities, clumsy sitting position, poor posture, obesity, and rarely trauma can cause a part of the intervertebral disc to degenerate and prolapse out of its place, exerting undue pressure over the nerve root and causing pain.
  • Patients complain of lower back pain, which goes down to either of the buttocks, thigh, calf, and legs.

An orthopaedic spine surgeon or a neurosurgeon can perform this procedure.

Preoperative preparation

  • A thorough clinical examination is essential to establish a clinico-radiological correlation.
  • Although sciatica is most commonly caused by herniated discs, other pathologies may mimic sciatica and need to be ruled out by clinical examination.
  • A spine X-ray may be performed to demonstrate lumbar list (sideward bending of the spine) and lordosis (reduced curvature), as well as instability. However, not all patients demonstrate these findings on an X-ray.
  • A subsequent spinal magnetic resonance imaging (MRI) might be needed to assess the status of the neural tissue. Further investigations would vary according to each patient.

Surgery

  • This procedure is usually carried out by an expert team including a spine surgeon, an anaesthetist, a physician, and a physiotherapist.
  • Microdiscectomy, which uses small incisions and causes less tissue trauma, is commonly carried out to relieve symptoms post-surgery.
  • Physiotherapy is essential to improve the mobility and overall surgical outcome.
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Laminectomy

Management Team

Laminectomy

Overview

Laminectomy is a surgical procedure done on the spine to manage stenosis (narrowing) of the spinal canal. The lamina is the bone of the spinal vertebra that lies behind it. Laminectomy is the removal of the lamina bone.

  • This procedure is indicated in patients who present with spinal stenosis (narrowing of the spinal cord) and nerve compression.
  • Sometimes laminectomy may be combined along with other spinal procedures, such as fixation to enhance the surgical outcome.

This procedure is performed by an orthopaedic spine surgeon or neurosurgeon. It is done from the back of the patient. After adequate exposure of the spine, the bone is removed with special instruments. This opens up the spinal canal and the neural elements are relieved of compression.

Preoperative preparation

  • Spine X-ray to reveal the spinal curvature.
  • Dynamic X-ray (by bending forwards and backwards) may be required to rule out any abnormal motion of the spine.
  • A subsequent spinal magnetic resonance imaging (MRI) might be needed to check the status of the neural structures. Further investigations would vary according to each patient.

  • This relatively simple procedure of the spine is carried out under general anaesthesia.
  • Patients experience relief of symptoms after surgery.
  • Analgesics are administered to relieve surgical site pain.
  • Rehabilitation involves physiotherapy exercises to increase the overall strength, confidence, mobility, and overall physical performance of the patient.
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Lumbar Pain

Management Team

Lumbar Pain

Overview

Lumbar pain is a discomfort or pain in the lower half of the back. It is caused by many conditions (like muscular spasms and ligament strain), spinal conditions (like compression and narrowing of the spinal canal), facet joint arthritis, instability, disc degeneration or infection, fracture of lumbar vertebrae, scoliosis, pain at the back of the abdomen, and tumour of lumbar spine.

  • Pain
  • Stiffness
  • Muscle spasm
  • Decreased mobility
  • Radiating pain to both lower limbs

  • Palpation of lower back, assessment of movements, and neurological examination.
  • X-rays to diagnose degenerative changes, fractures, or muscle spasm.
  • Spinal magnetic resonance imaging (MRI) to obtain details of soft tissue spinal cord and nerve roots and disc.
  • Computed tomography CT to determine occult fractures.
  • Nerve conduction studies for the assessment of nerve roots.

Non-surgical treatment

  • Pain medication  
  • Rest
  • Ice pack application
  • Epidural steroid injection, facet joint injection, or nerve root injection

Surgical treatment

  • Decompression through laminectomy and lumbar discectomy with or without spinal fusion
  • Fracture fixation
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Lumbar Canal Stenosis

Management Team

Lumbar Canal Stenosis

Overview

Lumbar canal stenosis is the narrowing of the spinal canal in the lumbar region (lower back) causing compression of the spinal cord and nerve roots. It is caused by age-related degeneration of the spine, disc herniation, ligamentum flavum hypertrophy, rheumatoid arthritis, tumours of the spine and spinal cord, and fractures.

  • Pain in the lower back with or without radiation to the lower limbs that increases on standing or walking (claudication) and is relieved by resting.
  • Stiffness leads to decreased mobility in the lower back muscles.
  • Weakness in the lower limbs, and bowel and bladder problems in the advanced stage of the disease.

  • Taking a thorough medical history.
  • Palpation of the lower back to identify the impacted region.
  • Tests, such as straight leg raising tests and nerve compression signs.
  • Assessment of movements and neurological examination.
  • X-rays: To assess the disc space, degenerative (wear and tear) changes, fractures, or loss of curvatures.
  • Magnetic resonance imaging (MRI): To assess the canal size, disc condition, and nerve compression.
  • Nerve conduction velocity and electromyographical studies: To assess the nerve roots and involvement of the muscles.

Non-surgical treatment

  • Non-steroidal anti-inflammatory medications
  • Rest
  • Ice pack application
  • Physical therapy to strengthen the core and paraspinal muscles
  • Steroid injections

Surgical treatment

Spine surgery is usually advised for patients in whom the non-surgical line of management failed and the neurological symptoms worsened.

  • Decompression: This involves surgically releasing the pressure on the affected nerve roots by making small openings in the bone.
  • Decompression and fusion: This involves releasing the compression on the nerve and addressing the bony instability using screws and rods.

Spine rehabilitation services are recommended for rapid recovery in patients undergoing surgery.

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