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Obstructive Jaundice

Management Team

Obstructive Jaundice

Overview

Jaundice refers to the yellow discoloration of the skin and eyes due to elevated levels of bilirubin in the blood.

  • Bilirubin: A chemical produced by the breakdown of red blood cells, processed by the liver, and excreted via bile.
  • Normal Bile Flow: Bile flows from the liver through bile ducts to the intestines, where it aids in digestion. Any disruption in this process can lead to jaundice.

Obstructive jaundice occurs when the normal flow of bile from the liver to the intestine is blocked. This leads to a buildup of bilirubin in the bloodstream, resulting in yellowing of the skin and eyes, dark urine, pale stools, and itching.

  • Medical Jaundice: Caused by liver dysfunction or systemic illnesses.
  • Surgical/Obstructive Jaundice: Caused by physical blockages in the bile ducts.

  • Medical Causes
    • Infections: Viral hepatitis (A, B, C, non A- non B, E)
    • Liver damage from medications, chemicals and drugs
    • Chronic liver diseases: Conditions like cirrhosis, primary biliary cholangitis, primary sclerosing cholangitis, or autoimmune hepatitis
    • Non-alcoholic fatty liver disease (NAFLD): Common in obese individuals or those with diabetes, leading to cirrhosis.
  • Surgical/Obstructive Causes of Jaundice
    • Gallstones: Stones that migrate to the bile ducts, causing blockage.
    • Tumours: Cancers of the liver, gallbladder, bile duct (cholangiocarcinoma), pancreas, or periampullary region.
    • Biliary Strictures: Narrowing of bile ducts due to scarring or inflammation.

  • Yellowing of the skin and eyes.
  • Dark urine and pale stools.
  • Itching due to bile salts in the skin.
  • Abdominal pain, nausea, or vomiting (depending on the cause).
  • Unexplained weight loss or loss of appetite (especially in cancer-related cases).

  • Blood Tests
    • Liver Function Tests (LFTs): Assess bilirubin levels and liver enzymes.
    • Other Blood Tests: To check for infections, blood counts, or tumor markers.
  • Imaging Studies
    • Ultrasound: Often the first test to identify obstructions or stones.
    • CT Scan/MRI/MRCP: Provide detailed images of the liver, bile ducts, and surrounding structures.
  • Endoscopy
    • Endoscopic Retrograde Cholangiopancreatography (ERCP): Visualizes and treats blockages, obtains tissue samples, and places stents to relieve jaundice.
    • Endoscopic Ultrasound (EUS): Helps in evaluating tumors or stones.

Medical Causes

  • Infections: Treated with antiviral or antibacterial medications.
  • Cirrhosis or NAFLD: Managed through lifestyle changes, medications, or, in severe cases, liver transplantation.

Surgical/Obstructive Causes

  • Gallstones
    • Cholecystectomy: Removal of the gallbladder, often performed laparoscopically.
  • Cancer or Tumours
    • Liver Resection: Removal of part of the liver for liver cancer or metastases.
    • Hilar Resection: Surgery to remove tumours blocking the main bile duct (hilar cholangiocarcinoma).
    • Whipple Procedure: Extensive surgery for cancers of the pancreas, bile ducts, or periampullary region.
  • Minimally Invasive Procedures
    • ERCP with Stenting: Temporary relief of jaundice by placing plastic or metal stents in bile ducts.
    • Stone Removal: Endoscopic extraction of stones blocking bile flow.
  • Advanced Cancer

Palliative Care

Focuses on symptom relief, including biliary drainage to improve quality of life.

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Oesophageal Cancer

Management Team

Oesophageal Cancer

Overview

Oesophageal cancer develops when abnormal cells in the lining of the oesophagus grow and multiply uncontrollably, leading to the formation of a tumour.

The most common subtypes of oesophageal cancer are:

  • Adenocarcinoma: typically occurs in the lower third of the oesophagus
  • Squamous cell carcinoma: Most often found in the middle and upper third of the oesophagus

Management strategies for both subtypes differ slightly based on specific pathology. 

  • Smoking
  • Alcohol consumption
  • GERD (Gastroesophageal Reflux Disease)
  • Barrett's oesophagus
  • Chewing tobacco, although less risky than smoking for oesophageal cancer, can still increase the risk by causing hyperacidity due to its irritant properties.

Early stages: 

  • Refractory hyperacidity
  • Difficulty swallowing solids or liquids, with food often feeling stuck in the oesophagus

Advanced stages:

  • Unexplained weight loss
  • Frequent vomiting after eating 
  • Pain in the chest or back
  • Hoarseness or change in voice

  • Upper Gastrointestinal (GI) endoscopy
  • Endoscopic ultrasonography (EUS)
  • Biopsy
  • Imaging tests, including CT and PET-CT scans
  • Barium swallow, although commonly used in the past, is now sparingly used for diagnosing oesophageal carcinoma.

Very Early Stages:

  • Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD)
  • Surgical removal of the oesophagus may be recommended, using conventional, video-assisted thoracoscopic surgery (VATS), or robotic approaches

Locally Advanced Cases:

  • For squamous cell carcinoma, treatment typically involves a combination of chemotherapy and radiotherapy in smaller doses, followed by surgery.
  • For adenocarcinoma, the sequence may involve administering chemotherapy first, followed by surgery, and subsequent chemotherapy as a follow-up.

Locally Advanced Cases Not Suitable For Surgery: 

  • A combination of definitive chemotherapy and radiation therapy maybe advocated

Cases with Metastatic Disease (spread beyond the oesophagus to the other organs of the body):

  • Chemotherapy or immunotherapy maybe used to manage the disease
  • Stenting can be performed to alleviate swallowing difficulties and improve quality of like

  • Avoid smoking and tobacco consumption in any form
  • Avoid or limit alcohol consumption
  • Manage GERD (hyperacidity)
  • Follow a healthy and balanced diet

Outcomes depend on the stage at diagnosis, overall health, and the chosen treatment approach.

If symptoms arise, consult a thoracic surgeon or a medical/radiation oncologist.

The specialist will recommend a treatment plan best suited for you based on your age, medical fitness, and the stage of the disease.

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Oral (Mouth) Cancer

Management Team

Oral (Mouth) Cancer

Overview

The oral cavity consists of essential structures, including the lips, gums, cheeks, tongue, floor of the mouth, palate, and jaws (mandible and maxilla).

When the cells lining these vital areas grow and multiply uncontrollably, they form malignant tumours, broadly termed as “oral cancer”. Among men in our country, oral cancer is the most common cancer and is strongly associated with tobacco chewing habits and poor oral hygiene.
The most prevalent type of oral cancer, accounting for over 95% of cases, is squamous cell carcinoma (SCC).

The primary cause for oral SCC is tobacco consumption, through smoking or chewing. Chewing habits involve substances like betel nut, lime, and other condiments (e.g., maava, masala). These are particularly harmful and produce serious effects on the oral lining, leading to oral submucous fibrosis, a condition frequently associated with oral cancer.

Other factors include:

  • Oral pre-malignant lesions, such as leucoplakia (white patches) and erythroplakia (red patches), often linked to chewing habits.
  • Poor oral and dental hygiene, including damaged or sharp teeth.
  • Alcohol, which acts as a compounding risk factor.

The most common symptom is a painless sore or ulcer that does not heal and may be accompanied by swelling.

As the disease progresses, additional symptoms may include:

  • Localized or radiating pain (e.g., to the ear or temple)
  • Difficulty in mouth opening
  • Foul breath
  • Disturbances in chewing, swallowing, and speech

Early diagnosis requires awareness and a high index of suspicion.

  • The most common diagnostic method is punch biopsy, which can be easily performed in the clinic.
  • Imaging techniques such as CT, MRI, or PET scans are essential for assessing the extent of the disease, staging it, and planning treatment.

Unfortunately, many patients present with advanced-stage cancers (Stages III and IV), despite the oral cavity being an accessible area.

Surgery remains the mainstay for treatment across all stages of oral cancer and is often the sole treatment for early cases. For advanced cancers (Stages III and IV), radiotherapy and chemotherapy may be added to improve outcomes. Emerging systemic therapies, such as targeted and immunotherapy, are expanding treatment options.

Further technological advances have provided benefits:

  • Advanced imaging techniques enable precise treatment planning.
  • 3-D printing and modelling significantly enhance restorative efforts.
  • Routine use of microvascular reconstruction has transformed surgical outcomes, improving survival and quality of life.
  • Molecular and genetic sequencing now assist in managing complex cases.

The most effective prevention strategy involves raising awareness and eliminating tobacco use and other chewing habits, which are responsible for over 50% of all cancers and related deaths.

Promoting good oral and dental hygiene is also critical in combating the “cancer epidemic”.
Early diagnosis plays a vital role in improving outcomes.

If you suspect or have been diagnosed with oral cancer, consult a surgical oncologist who specialises in its treatment.

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Ovarian Cysts

Management Team

Ovarian Cysts

Overview

Ovarian cysts are pouch-like structures filled with liquid or semi-solid material that form in your ovaries. They can either form either within the ovary or on the ovarian surface. Rarely, some ovarian cysts become malignant (cancerous) and/or cause serious complications; less than 1% of ovarian cysts are cancerous. Most ovarian cysts are benign (harmless) and are cleared on their own. However, very heavy cysts can cause ovarian torsion, a condition in which the ovary turns over on itself one or more times, leading to reduced or zero blood flow to the ovary, necessitating surgery.

Based on their development, ovarian cysts can be broadly categorised into two classes:

  • Functional cysts: These cysts develop as a part of the ovulation cycle (the release of an egg from the ovary) and are a sign of properly functioning ovaries; these cysts generally shrink over time.
  • Pathological cysts: These cysts are formed as a result of abnormalities and are much less common than functional cysts. Pathological cysts include:
    • Cystadenomas: Fluid-filled cysts that form on the ovarian surface.
    • Dermoid cysts (teratomas): Cysts containing cells from all types of tissues (hair, teeth, skin, and even brain tissues).
    • Endometriomas: Cysts filled with endometrial tissue, i.e., the same tissue that lines your uterus and bleeds during the menstrual cycle.
    • Ovarian cancer cysts: Ovarian tumours (solid masses of cancer cells).

Hormonal changes during ovulation are the main cause of ovarian cysts. Other causative factors include:

  • Endometriosis: Ovarian cysts can form in advanced stages of endometriosis, a condition in which tissue similar to the uterine lining (womb lining) grows in places outside the womb.
  • Pelvic inflammatory disease (PID): Severe PID—an infection of the female reproductive system, usually caused by bacteria from sexually transmitted infections—can cause scarring and cyst formation in the ovaries. Women with PID are more likely to develop ovarian cysts that are infected with bacteria. Rupture of such cysts can lead to sepsis.
  • Genetics: Some women may be at a high risk of developing ovarian cysts owing to their genetic background.
  • Obesity: The underlying hormonal imbalances associated with obesity have been reported to increase the risk of ovarian cyst formation.

Most women with ovarian cysts may not exhibit any noticeable symptoms, especially if the cysts are small. However, large cysts or cyst rupture can result in various symptoms, including: 

  • Pelvic pain: You might experience pain on one side of the pelvis (the region below your bellybutton). The pain levels vary, ranging from a dull, persistent heavy sensation to an unexpected, severe, and sharp pain.
  • Bloating: You may have a feeling of fullness or heaviness in your belly.
  • Changes in the menstrual cycle: You might suffer from irregular periods, abnormal bleeding, or painful periods.
  • Pain during intercourse: You might feel discomfort during sex.
  • Urinary symptoms: You might experience difficulty in emptying the bladder or there might be an increased urgency to urinate.
  • Difficulty in bowel movement: You might face bowel movement problems, such as constipation or pain during bowel movements.

  • Pelvic examination: In this examination, a doctor physically checks for any abnormal masses (lumps) or tenderness in the pelvic region.
  • Ultrasound: This sound wave-based imaging procedure can help determine the size, type (cystic, solid, or both), location, contents, and appearance of the cyst, in addition to providing details regarding the vascular content, i.e., blood vessels penetrating the cyst. Patients undergoing ultrasound for ovarian cysts must drink a lot of water at least one hour before the appointment and avoid emptying their bladder before the procedure.
  • Blood tests: As hormonal imbalance can cause ovarian cysts, the serum levels of reproductive hormones (luteinising hormone (LH), follicle-stimulating hormone (FSH), oestradiol, and testosterone) are measured to determine the cause of ovarian cysts.
  • Cancer antigen 125 (CA 125) test: As CA 125 levels can increase when a person has ovarian cancer, the CA 125 test is suggested for women with ovarian cysts, especially if they are postmenopausal, have a high risk of developing ovarian cancer, or if the cyst is suspected to be cancerous.
  • Magnetic resonance imaging (MRI): In rare cases, more advanced imaging methods are required to diagnose ovarian cysts. MRI can accurately differentiate between harmless and cancerous ovarian masses with 88‒93% accuracy. They can identify different types of material in ovarian cysts, including fat, fluid, solid, and haemorrhage.
  • Computed tomography (CT): Though CT is not typically used to evaluate ovarian cysts, it is the best technique for imaging haemorrhagic ovarian cysts (ovarian cysts filled with blood).

Generally, if the cyst is small and is not causing too much difficulty to the patient, doctors usually recommend monitoring the cyst over a few menstrual cycles as most cysts tend to get cleared on their own. For cysts that persist and are associated with complications, the treatment depends on several factors, including cyst type and size and patient age. Here are some common treatment options:

  • Medications: Hormonal contraceptives or birth control pills—that help regulate the menstrual cycle—can prevent the development of new ovarian cysts, but they cannot resolve the existing ones. Over-the-counter painkillers (e.g., acetaminophen (Tylenol), ibuprofen (Advil), naproxen (Aleve)) and can temporarily relieve ovarian cyst‒related pain. Narcotic medications like oxycodone and morphine sulphate are recommended for moderate to severe pain.
  • Laparoscopic ovarian cystectomy: Laparoscopy may be recommended for noncancerous cysts that are less than 3 inches in size. In this procedure, a camera is inserted through a cut in the abdomen and the pelvis is inflated with gas to create extra space for accessing the ovaries. Then, a few more small cuts are made to insert the surgical tools and remove the cyst. Patients undergoing this surgical procedure can go home the same day.
  • Ovarian cystectomy (Laparotomy): Laparotomy may be recommended for cysts that are particularly large or potentially cancerous. In this surgery, a single, large cut is made in the abdomen to access and remove the cyst. Patients need to stay in the hospital for a few days after surgery and avoid heavy physical work for some days.

  • You experience severe pelvic pain or abdominal pain.
  • You exhibit symptoms of a ruptured cyst, e.g., sudden, sharp pain, nausea, vomiting, or faintness.
  • You notice changes in your menstrual cycle or unusual bleeding.
  • When your urinary or bowel symptoms persist.
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Obsessive Compulsive Disorder (OCD)

Management Team

Obsessive Compulsive Disorder (OCD)

Overview

Obsessive compulsive disorder (OCD) consists of two key components: obsession and compulsions. Obsessions are recurrent, persistent, and anxiety-provoking and intrusive, unwanted thoughts, urges or images. Compulsions, on the other hand, are repetitive behaviours or rituals performed in response to these obsessions to alleviate anxiety and distress. Common obsessions include fear of contamination, which is usually accompanied by compulsive hand washing.

The exact cause is unknown. Some risk factors include:

  • Genetics
  • Childhood trauma
  • Brain structure

  • Fear of contamination
  • Fear of misplacing things
  • Desire to look appealing

OCD is diagnosed through

  • Physical examination
  • Psychiatric evaluation.

  • Psychotherapy
  • Medications
  • Deep brain stimulation
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Oesophageal Varices

Management Team

Oesophageal Varices

Overview

Oesophageal varices, i.e., expanded oesophageal veins, primarily occur in response to elevated blood pressure in the portal vein that transports blood from the intestines and spleen to the liver. This elevated portal vein pressure (a condition known as portal hypertension) causes blood to be rerouted through smaller veins, including those in the oesophagus, which can become engorged and prone to rupture. Oesophageal varices are a serious medical condition because if they rupture, they can lead to severe bleeding, which can be life-threatening.

As specified above, the predominant cause of oesophageal varices is portal hypertension, and therefore, all factors that cause portal hypertension are also the factors responsible for oesophageal varices; these include:

  • Cirrhosis of the liver: In cirrhosis, the blood-filtering ability of the liver is impaired, leading to an increase in portal vein pressure.
  • Chronic liver diseases: Chronic conditions like viral hepatitis, fatty liver disease, or alcoholic liver disease can cause progressive liver damage that culminates in cirrhosis, which leads to portal hypertension.
  • Portal vein thrombosis: Blood clots formed in the portal vein obstruct normal blood flow, causing increased blood pressure in the portal venous system, ultimately leading to varices.
  • Schistosomiasis: In certain geographies, particularly parts of Africa and Asia, liver flukes are common. Upon infection (schistosomiasis), the eggs of these parasites get lodged in various tissues, especially liver, and trigger an inflammatory reaction that leads to hypertension, thereby contributing to varices.
  • Congenital abnormalities: Rarely, portal hypertension can be caused by congenital conditions such as portal vein malformations.

Initially, oesophageal varices are asymptomatic (no noticeable symptoms); however, later on, the varices begin to bleed. The observed symptoms are mostly of the complications. The symptom trends for these conditions have been described below. 

  • Uncomplicated oesophageal varices (no bleeding):
    • None or mild symptoms: In many cases, oesophageal varices are asymptomatic and are only discovered during an endoscopy or imaging study for another condition (e.g., liver disease).
    • Signs of liver disease: Patients with oesophageal varices often have signs of liver failure, like yellow skin (jaundice), excess fluid in the abdomen (ascites), and enlarged spleen (splenomegaly).
  • Bleeding oesophageal varices (most serious complication):
    • Hematemesis (vomiting blood): The most dramatic and dangerous symptom of bleeding oesophageal varices is vomiting bright red blood or coffee-ground-like material (which indicates partially digested blood).
    • Melena: Black, tarry stools, indicating the presence of digested blood from varices that have bled into the stomach.
    • Hypovolemic shock: When varices rupture and bleed heavily, the person can go into shock. Symptoms of shock include:
      1. Dizziness or fainting
      2. Pale or cold extremities
      3. Rapid heartbeat (tachycardia)
      4. Low blood pressure (hypotension)
      5. Confusion or altered mental status due to loss of blood.

Oesophageal varices are often suspected in cases of chronic liver disease or portal hypertension and confirmed through a variety of tests; these include:

  • Endoscopy (gastroscopy):
    • Esophagogastroduodenoscopy or EGD: This is the best diagnostic modality for oesophageal varices. During the procedure, a camera bound to a fine tube is endoscopically guided via the mouth to visualise the interior of the oesophagus and assess the size and severity of any varices. This modality can also detect signs of bleeding or red spots on varices, which indicate a higher risk of rupture.
  • Imaging:
    • Doppler ultrasound: This technique can assess the flow of blood through the liver and portal vein, which helps in diagnosing portal hypertension.
    • CT and MRI: These techniques can determine the severity of portal hypertension or any complications, such as a portal vein thrombosis.
    • Endoscopic ultrasound: This technique can be used to assess the varices in more detail, especially if there is bleeding risk.
    • Liver function tests: These tests help diagnose the underlying liver disease that might be causing portal hypertension and include:
      1. Liver enzyme tests (ALT, AST, ALP)
      2. Bilirubin tests
      3. Prothrombin time assessment (to assess clotting function)
      4. Albumin tests

  • Prevention of bleeding (primary prophylaxis):
    • Non-specific beta-blockers (e.g., propranolol or nadolol): These medications reduce portal hypertension and lower the risk of variceal bleeding. Further, they reduce blood flow to the oesophagus, helping prevent varices from expanding or rupturing.
    • Endoscopic variceal ligation (EVL): This technique involves stopping blood flow and preventing rupture by ligating the varices using a small rubber band. It is often employed for larger varices or high-risk patients.
    • Endoscopic sclerotherapy: In this technique, variceal shrinkage and sealing is induced by introducing a sclerosing agent into the varices. This modality is not employed very often but may be an option for some patients.
  • Acute bleeding (emergency treatment):
    • Stabilisation: The first step after bleeding is patient stabilisation via fluid resuscitation (IV fluids or blood transfusions) to manage blood loss and restore blood pressure.
    • Endoscopic treatment: Once the patient is stabilised, EVL treatment of choice for acute bleeding varices is used to stop bleeding. If EVL is not successful, endoscopic sclerotherapy or balloon tamponade (a technique in which an endoscopically guided inflatable balloon is used to tamponade (compress) the bleeding varices) may be employed.
    • Pharmacologic therapy: Vasopressin or octreotide (somatostatin analogue) may be used to reduce portal pressure and control bleeding. These medications constrict blood vessels and help stop the bleeding.
    • Transjugular intrahepatic portosystemic shunt (TIPS): It may be used for refractory cases where bleeding cannot be controlled. TIPS involves implanting a stent between the portal and hepatic veins; this creates a shunt that allows blood to flow directly from the portal vein to the hepatic vein, thereby reducing portal pressure, and by extension, varices.
    • Surgery: In severe cases where other treatments fail, surgery (such as oesophageal devascularisation or a liver transplant) may be needed.

  • Regular monitoring for varices in individuals with liver disease, especially cirrhosis can help prevent varices.
  • Lifestyle changes (e.g., refraining from smoking and drinking) and managing hepatitis can diminish the risk of liver disease progression.
  • Prompt treatment of liver disease (including medications, lifestyle changes, and, in some cases, liver transplantation) can help prevent varices.
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Oesophageal Strictures

Management Team

Oesophageal Strictures

Overview

Types of oesophageal strictures. EoE, Eosinophilic esophagitis

Oesophageal strictures refer to the narrowing or tightening of the oesophagus, which can cause difficulty swallowing (dysphagia), regurgitation, and discomfort. These strictures are caused by varied factors, including inflammatory, neoplastic, traumatic, and congenital factors. The narrowing can be partial or complete, and the degree of severity can vary. Oesophageal strictures can develop over time and lead to progressive difficulty in swallowing.

Strictures can be broadly classified based on their aetiology (underlying cause) and the mechanisms involved in their formation.

  • Benign oesophageal strictures: These are non-cancerous strictures caused by chronic injury, inflammation, or scarring of the oesophageal lining.
    • Corrosive strictures
    • Radiation-induced strictures
    • Eosinophilic esophagitis (EoE) strictures
    • Post-surgical strictures
    • Achalasia-related strictures
  • Peptic (gastroesophageal reflux disease - GERD) strictures
  • Malignant oesophageal strictures: These strictures occur due to oesophageal cancer or metastatic cancer that involves the oesophagus.
  • Congenital oesophageal strictures: These strictures are present at birth and are relatively rare.
  • Congenital oesophageal atresia with strictures

TypeCauseRegion affectedSymptoms
Peptic (GERD) strictureChronic acid reflux causing fibrosisDistal oesophagus (near LES)Dysphagia, heartburn, regurgitation
Corrosive strictureIngestion of caustic substances (acids or alkalis)Middle to distal oesophagusImmediate pain, dysphagia, aspiration
Radiation-induced strictureRadiation therapy for cancersMiddle to distal oesophagusDysphagia, chest pain
Eosinophilic esophagitis (EoE) strictureChronic allergic inflammationProximal to mid-oesophagusDysphagia, food impaction
Post-surgical strictureScarring after surgery (e.g., fundoplication, esophagectomy)Near the site of surgeryDysphagia, regurgitation
Achalasia-related strictureDysfunctional motility in achalasiaDiffuse, often at LES*Progressive dysphagia, regurgitation
Metastatic strictureSpread from primary cancersAny part of the oesophagusDysphagia, weight loss, regurgitation
Congenital strictureAbnormal foetal development (atresia, webs)Upper oesophagusFeeding difficulties, aspiration (in neonates)

*LES, Lower oesophageal sphincter

  • Gastroesophageal reflux disease (Peptic Stricture)
  • Eosinophilic oesophagitis: An allergic condition where eosinophils (a type of white blood cell) infiltrate the oesophagus, leading to inflammation and fibrosis. (EoE stricture)
  • Radiation therapy
  • Achalasia
  • Corrosion-related oesophageal injury: Injuries caused by swallowing corrosive substances, like acids or alkalis, can result in strictures. (Corrosive stricture)
  • Infections: Certain infections (like candida or herpes) may cause oesophageal damage, leading to stricture formation.
  • Surgical complications (Post-surgical stricture)
  • Oesophageal cancer (Malignant stricture)
  • Hiatal hernia
  • Peptic ulcers
  • Foreign body ingestion
  • Congenital issues
  • Plummer-Vinsion syndrome
  • Family history of allergies or asthma
  • Age

  • Dysphagia (difficulty swallowing)
  • Odynophagia (painful swallowing
  • Regurgitation
  • Weight loss
  • Heartburn
  • Coughing or choking
  • Persistent hiccups

  • Upper endoscopy (esophagogastroduodenoscopy, EGD): This is the most definitive diagnostic tool for oesophageal strictures. During EGD, a camera bound to a fine tube is guided into the oesophagus through the mouth to confirm or negate the presence of a stricture and take biopsies if needed. Endoscopy also helps assess the degree of damage (inflammation, ulceration, and scarring).
  • Barium swallow (X-ray): A contrast study where the patient swallows a barium solution, allowing radiologists to see the contours of the oesophagus and identify any narrowing or blockages. This technique can show the location and extent of the stricture, and is useful for assessing motility
  • Oesophageal manometry: This test measures the pressure and muscle function and motility of the oesophagus and lower oesophageal sphincter.
  • CT or MRI: These imaging modalities can determine stricture position and severity, and rule out other causes, such as tumours.

  • Endoscopic treatment: This is generally performed for established strictures.
    • Endoscopic balloon dilation: One of the primary treatments for oesophageal strictures is endoscopic dilation, where a balloon is inflated to stretch the narrowed part of the oesophagus.
    • Laser therapy: It may be used for treating strictures, particularly if the narrowing is severe or resistant to dilation.
    • Oesophageal stenting: If dilation is ineffective or the stricture recurs frequently, a stent might be inserted to keep the oesophagus open. This is usually considered a temporary or adjunctive solution.
  • Neutralisation: In case of corrosive strictures, or strictures caused by ingestion of a chemical, neutralisation of the chemical immediately after consumption is an effective management strategy.
  • Medications:
    • Proton pump inhibitors (PPIs): If the stricture is caused by GERD, PPIs can reduce acid production, decreasing further damage to the oesophagus.
    • H2-receptor antagonists: Similar to PIPs, these antagonists also decrease stomach acid production; however, these are less effective.
    • Antacids: These can provide temporary relief for heartburn symptoms.
    • Corticosteroids: For eosinophilic oesophagitis, corticosteroids can reduce inflammation and prevent further scarring.
    • Antibiotics or antifungals: If an infection (such as Candida) is the cause, appropriate antimicrobial therapy will be needed.
  • Surgical intervention: In severe cases or when dilation fails, surgery may be required. This could involve cutting away the affected portion or creating a bypass.
  • Dietary modifications: Patients are often advised to avoid foods that might irritate the oesophagus, particularly acidic or spicy foods. Depending on stricture severity, a soft food diet or liquid diet might be recommended.
  • Management of underlying conditions: Treating the underlying cause, such as controlling GERD, managing eosinophilic oesophagitis, or treating achalasia, is crucial for preventing recurrence of strictures.
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Oesophageal Cancer

Management Team

Oesophageal Cancer

Overview

Oesophageal cancer refers to a cancerous tissue (tumour) that has its origins in the lining of the oesophagus but can spread deeper and upwards or downwards along the food pipe. This rare entity is often diagnosed at an advanced stage as patients do not realise that they are affected until the tumour is big and obstructs the oesophageal lumen.

Oesophageal cancers are of the following three types:

  • Adenocarcinomas: They originate from glandular cells, which are located in the lower part of the food pipe, i.e., near the stomach.
  • Squamous cell carcinomas: They originate from the squamous cells that line the upper and middle parts of the food pipe.
  • Other rare types of oesophageal cancers: Though most oesophageal cancers are adenosarcomas or squamous cell sarcomas, other rarer types exist.
    • Small cell cancers: The origins of this cancer are not clear.
    • Soft tissue sarcomas: These originate from cells of tissues that support and protect organs.
    • Poorly differentiated neuroendocrine cancers: These originate from cells of the neuroendocrine system.

  • Gastroesophageal reflux disease (GERD)
  • Acid reflux
  • Obesity and overweight
  • Smoking and drinking
  • Vegetable & fruit-poor diets
  • Age
  • Achalasia
  • Chronic irritation or injury to the oesophagus

Oesophageal cancer may be asymptomatic (no noticeable symptoms) initially; however, with disease progression, symptoms may appear. These symptoms include:

  • Dysphagia (difficulty swallowing
  • Unexplained weight loss
  • Chest pain
  • Regurgitation of food
  • Hoarseness
  • Chronic cough
  • Indigestion or heartburn
  • Vomiting or coughing up blood (in more advanced stages)

  • Endoscopy: This method involves visualising the interior of the oesophagus and possibly suspicious using a camera attached to a very fine, flexible tube.
  • Endoscopic ultrasound: This technique helps determine tumour size and evaluate tumour metastasis, i.e., spread to nearby tissues or lymph nodes.
  • Imaging tests: CT, MRI, or PET are used to assess cancer spread (metastasis).
  • Biopsy: This technique is used to detect cancer cells in the oesophageal tissue.

  • Surgical approach: In some cases, removing the tumour through surgery is an option. This may involve partial or total removal of the oesophagus (esophagectomy).
  • Endoscopic therapy: For early-stage cancers, techniques like laser therapy or photodynamic therapy may be used to eliminate cancer cells.
  • Radiation therapy: This modality involving high-energy irradiation either alone or in conjunction with chemotherapy can be used to target and kill abnormally growing cells (tumour cells).
  • Chemotherapy: This modality generally used in combination with other treatments eliminates cancer cells and restricts their growth.
  • Targeted therapy: This strategy involves using drugs e.g., trastuzumab (HER2 inhibitor), bevacizumab (VEGF inhibitor), and EGFR inhibitors that target key molecules driving cancer cell growth and survival. It offers new options for managing advanced or metastatic disease.
  • Immunotherapy: Checkpoint inhibitors like pembrolizumab and nivolumab have emerged as important treatment options for individuals with advanced oesophageal cancer, especially those with high PD-L1 expression.

Consult a medical professional if you have difficulty swallowing, unexplained weight loss, or other persistent symptoms like long-standing acidity and heartburn.

  • Avoiding smoking and excessive alcohol use.
  • Maintaining optimal weight and having a balanced diet.
  • Orderly screening of high-risk individuals, especially those having chronic GERD or a history of oesophageal conditions.
  • Managing GERD symptoms and Barrett’s oesophagus (if present).
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Oesophageal Dysmotility due to Gastroesophageal Reflux Disease (GERD)

Management Team

Oesophageal Dysmotility due to Gastroesophageal Reflux Disease (GERD)

Overview

GERD can lead to oesophageal motility dysfunction owing to improper closing of the lower oesophageal sphincter (LES) and subsequent stomach acid to reflux into the oesophagus.

Chronic acid exposure due to GERD: GERD can lead to hypotension of the LES (a condition where the LES does not maintain the pressure required to prevent the backflow of the stomach contents into the oesophagus) as well as impaired oesophageal peristalsis, often due to chronic acid exposure.

  • Heartburn
  • Regurgitation
  • Chest pain
  • Dysphagia
  • Sensation of a lump in the throat

  • Oesophageal manometry: This condition may manifest as reduced peristalsis and LES dysfunction in oesophageal manometry.
  • 24-hour pH monitoring: This is often employed to confirm acid reflux.

  • Medications:
    • Antacids, PPIs, and H2 receptor antagonists: These may be used to reduce acid production.
    • Prokinetic agents: These agents (e.g., metoclopramide and domperidone) may be used to improve oesophageal motility.
  • Fundoplication surgery: In some cases, fundoplication surgery to repair the LES may be considered.
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Oral Health

Management Team

Oral Health

This procedure involves the removal of a tooth from the gum socket; one or more teeth may be removed. To avoid infections, the dentist may prescribe antibiotics before the procedure.

  • A local anaesthetic is administered to numb the area around the tooth (to avoid any sensations of pain).
  • A tooth removal instrument called an elevator may be used to loosen the tooth in the gum.
  • Tooth extraction forceps are then placed around the tooth to pull it out of the socket.

These orthodontic devices, often made of metal or porcelain, are attached to the teeth. To create a gentle tug or force that helps the teeth move into the correct position, metal wires and rubber bands are used.

Aligners represent a unique type of orthodontic devices that are made of plastic; often they are custom-made to fit the teeth. Each aligner moves the teeth towards the final (desired) position in a step-by-step manner. To enable the aligner to grip the tooth and reposition it correctly, small heaps of composite resin (tooth-coloured filling material) are attached to various teeth.

Porcelain veneers are one of the most popular treatment options in cosmetic dentistry. Veneers are thin shells of porcelain, which are placed over the natural teeth to help correct almost any smile flaw, such as the following:

  • Open gaps between teeth
  • Cracked or broken teeth
  • Crooked teeth
  • Ground down teeth
  • Stained teeth

Procedure:
The first step during the treatment is to remove a small amount of enamel from the tooth. This will make room for the veneers. Impressions will be taken and sent to the lab to manufacture the porcelain veneers.
Once the veneers are back, the fit and colour will be assessed to achieve the right result. Thereafter, the shells will be bonded onto the teeth and dried with a special light
to achieve an aesthetic smile.

Dental implants offer the possibility of replacing a lost permanent tooth. Dental implants are small titanium posts directly placed into the jawbone to replace a missing tooth root. These act as a foundation for common dental restorations, renewing the patient’s ability to chew, speak and smile with full confidence.
There are multiple ways implants can be used to restore the smile, including:

  • Replacing a single tooth or multiple teeth
  • Application of supporting and stabilising dentures
     

Preparation
During the first appointment, a dental and medical examination and 3D X-ray imaging will be performed to determine if the patient is an appropriate candidate for implants; accordingly, a treatment plan will be designed. Then, the titanium implant is then surgically inserted into the jawbone. The implant will fuse with the jawbone, a process called osseointegration; this usually requires up to 3 months. Once the complete fusion of the implant with the jawbone is achieved, the abutment will be placed to serve as an anchor to the restoration. A customised restoration will then be placed on top of the implant for functionality and aesthetics.

A removable partial denture (RPD) is a dental prosthesis that is used to replace multiple missing teeth. If a patient is not a candidate for a fixed dental bridge or dental implant, then an RPD is a good option. Generally, RPDs are worn during the day in order eat comfortably and smile aesthetically. At night the RPD can be removed to clean it and give the tissues in the mouth a break from the prosthesis.

These consist of two main parts: the artificial teeth and denture base. An artificial tooth restores the natural tooth's appearance and its occlusion and oral function, also assisting the patient in pronouncing words correctly. The dental base serves as the foundation of the artificial tooth; it is often used to restore defective soft and hard tissues. Biting force is distributed from the artificial tooth to the denture base, and finally, to the oral mucosa and bone tissues. Given that tooth support cannot be obtained, the denture base of complete dentures covers a larger area of the oral mucosa.

This is a partial denture comprising a cast metal framework with acrylic resin prosthetic teeth. Removable partial dentures with cast metal frameworks are markedly more advantageous than the more regularly used partial dentures. These denture frameworks are custom-made to match the shape of each patient’s teeth. Because they fit onto the teeth and are connected to them, they are extremely stable and retentive.

A palatal obturator is a short-term prosthesis that completely occludes openings in the roof of the mouth (for example, oronasal fistulas). After surgery, residual oronasal openings may remain on the palate, alveolar ridge, or vestibule of the larynx. Thus, palatal obturators are typically used to close such openings in the hard/soft palate; these defects/openings may cause nasal regurgitation during feeding or affect speech. These obturators are useful for the correction of hypernasality and aid in speech therapy, serving as a plastic/acrylic, removable roof of the mouth, that aids in speech and eating and the maintenance of proper air flow.

A dental crown often serves as a cap for an individual's damaged or decaying tooth or as a replacement for a missing tooth when placed on top of a dental implant.

Bridges are solely used to replace missing teeth. They have two crowns (one on each end) and a series of replacement teeth that rests in an area within the gums where there is tooth loss. These crowns can be fused to existing teeth or attached to dental implants.

At the Sir H. N. Reliance Foundation Hospital, we have a solution to bring back the brightness and vigour of your smile. Pola office is an in-office professional teeth whitening system that aims to brighten your teeth permanently while reducing tooth sensitivity. Widely recognised as one of the most effective teeth whitening systems. Pola office whitening offers cost-effective solutions and astonishing results for all patients.

We start the procedure by establishing your smile goals. This includes customising the shade of composite resin to match the shade of your current teeth or choosing your desired shade.
The next step is to roughen the surface of the tooth and add a bonding and conditioning liquid. This step is necessary to help the material bond better to your natural tooth. We then add the composite material layer by layer and shape it until it is of the correct shape.
The material is hardened using a special light and your teeth are polished. The result will be a cavity free dentition that would restore your oral health.

Brushing and flossing twice a day is important for a healthy smile. However, some places can be tough to reach with a conventional toothbrush or floss. Many patients find it difficult to remove food impacted between the molars due to irregular pits and grooves on the surface. Dental sealants are a thin plastic coating painted onto the teeth by our dentists. Using sealant acts as a preventative measure, which fills the pits and grooves on tooth surfaces. It helps preventing food impaction, which can lead to decay and eventually cavities. Sealants can be used on adults as well as in children.

This helps connects a tooth that has undergone a root canal to a dental crown. To place a post, first, a root canal is performed on the desired tooth/teeth to eliminate the infection; the root canal is shaped to receive the post. A small instrument known as a dental file is used to shape the top of the root canal; after a post is selected, it is cemented or bonded into place. Once the post is in place, the tooth is filled with the new core material. Once this material has hardened, the core material is shaped and prepared such that it can receive a dental crown. An impression of each patient’s teeth are prepared so that a dental laboratory can custom-craft a crown that will precisely fit the post and core build up.

When a tooth becomes severely decayed or infected, a root canal might be necessary. This is due to caries reaching the nerve leading to an infection.
In order to save your tooth and restore its function, we will gently remove the infected pulp and all the bacteria. Then, we will fill the space within the tooth with composite resin to restore its strength.

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