Disease that hits digestive system
Dr Vivek Sharma

Birthday cakes, pizza, chocolate cookies, etc, for children with celiac disease — a disorder of the digestive system — aren’t always the treats that most people think they are. Why? They usually contain gluten, a type of protein, which causes problems for people with celiac disease.

Celiac disease damages the small intestine and interferes with the absorption of nutrients from food.

The causes

People who have celiac disease cannot tolerate gluten. The destruction of the inner lining of the small intestine in people suffering from celiac disease is caused by an immunological (allergic) reaction to the gluten in the diet that inflames and damages the inner lining of the small intestine.

This reaction is partially genetic and inherited. Thus, approximately 10 per cent of the first-degree relatives (parents, siblings or children) of individuals with celiac disease also will have this illness.

What is gluten?

Rye, barley and wheat are the main sources of gluten, which is a family of proteins. Further, gliadin is the part which causes celiac disease particularly.

Gluten may also be found in products we use everyday such as stamp and envelope adhesive, medicines and vitamins.

Symptoms

The disorder does not present itself until gluten products have been introduced into the diet. The most common period of presentation is between six months and two years of age.

Recognising celiac disease can be difficult because its symptoms are similar to those of other diseases. But some of the classical symptoms of the disease include failure to gain weight, diarrhoea, irritability, vomiting, anorexia, foul stools, abdominal pain, excessive appetite, growth retardation, wasted muscles, abdominal distension, edema, finger clubbing, etc.

What is the treatment?

The only treatment for celiac disease is to follow a gluten-free diet. A gluten-free diet means not eating foods which have wheat, rye and barley products.

Tips for parents

(a) No medication exists at present; the only effective treatment is life-long gluten-free diet.

(b) Dietician input is generally requested to ensure that the patient is aware which food contains gluten, which food is safe and how to have a balanced diet despite the limitations.

(c) The diet can be cumbersome; failure to comply with the diet may cause relapse.

(d) Checking the market products are important. Many corn and rice products come from factories that also manufacture wheat items.

(e) One should check the hidden sources of gluten, including additives such as modified food starch, preservatives and stabilisers. Wheat and wheat products are often used as thickeners, stabilisers and texture enhancers in foods.

(f) Gluten is also used in some medicines.

(g) Children with celiac disease have to he extremely careful about what they buy for lunch at school, what they purchase at the grocery store, what they eat at restaurants or parties or what they grab for snack. Eating out can be a challenge.

(h) But with practice, screening for gluten becomes a second nature.

The writer is a consultant paediatrician at Rungta Hospital, Jaipur. Email: drvivek_sharma @rediffmail.com

Blood in urine? It may be cancer
Dr Santosh Kumar

The greatest risk factor for bladder cancer is smoking. Carcinogens (cancer-causing chemicals) in tobacco smoke are absorbed from the lungs and get into the blood. From the blood, they are filtered by the kidneys and concentrated in urine. These chemicals in urine damage the cells that line the inside of the bladder. This damage increases the chance of cancer developing.

Chemicals called aromatic amines, such as benzidine and beta-naphthylamine, which are used in the dye industry, can cause bladder cancer. The industries carrying highest risks include the makers of rubber, leather, textiles and paint products and printing companies. Other workers with an increased risk of developing bladder cancer include painters, hairdressers, machinists, printers and truck drivers. The risk of bladder cancer increases with age. The risk of men getting bladder cancer is four times greater than women

What are the signs and symptoms of urinary bladder cancer?

Blood in the urine (hematuria) is the first warning signal of bladder cancer. But do not panic when you see blood in urine. More often it is caused by other things such as infection, benign tumours, stones in the kidney or bladder. Blood may be present one day and absent the next day with urine remaining clear for weeks or months. With bladder cancer, blood eventually reappears.

Usually, the early stages of bladder cancer cause bleeding but little or no pain. Change in bladder habits or irritative symptoms such as dysuria (burning during urination) and urgency can also be symptoms of bladder cancer. However, these symptoms are also more likely to be caused by other factors like an overactive bladder or an enlarged prostate.

How is bladder cancer treated?

Transurethral surgery: For early stage or superficial bladder cancers, a transurethral resection (TUR-BT) is most common. For this operation, a type of rigid cystoscope called resectoscope is placed into the bladder through the urethra (penis). As the resectoscope has a cutting wire loop at its end to remove tissue, the urologist can see into the bladder and remove the tumour.

The removed tissue is sent to a pathologist for examination. Further treatment depends on the biopsy report. Since about 70 to 80 per cent patients have superficial cancer when they are first diagnosed, it does not involve cutting 
into the abdomen.

Intravesical therapy: Intravesical therapy is a treatment in which medicine is put directly into the bladder (through a catheter). The most common intravesical therapy used in bladder cancer is Bacillus Calmette-Guerin (BCG). This treatment causes the body’s own natural defences (immune system) to attack the bladder cancer. BCG has got more side-effects. Chemotherapy drugs like gemcitabine can also be used in intravesical therapy and are equally effective.

Radical cystectomy: When bladder cancer is invasive, ie the root is deep, all or part of the bladder may need to be removed.

Reconstructive surgery: If the whole bladder is removed, one will need another way to store and remove urine. Several types of reconstructive surgery can be done depending on the medical situation and personal preferences.

One possibility is to remove a short piece of the intestine and use it as a passage-way for urine to pass from the kidneys to the outside of the body (stoma). Urine empties continuously into a small bag placed over the stomach.

A newer method routes the urine back into the urethra restoring close to normal urination. One way to do this is to create a neobladder — a urinary reservoir made of a piece of intestine. This allows the patient to urinate normally.

Chemotherapy can be given after the tumour has been removed with surgery. This is called adjuvant therapy.

The goal of adjuvant therapy is to kill any cancer cells that remain after surgery (but are too small to see). This can lower the chance that the cancer will come back later.

Complications of surgery and anaesthesia are medical problems like pneumonia, lung collapse and cardiac problem if the patient is having cardiac problems. Surgical complications include bleeding, intestinal obstruction, infection, urinary leakage, sexual problems and cancer recurrence.

The writer is Assistant Professor, Department of Urology, PGI, Chandigarh.

Knee pain — early management prevents disability
Dr Ravinder Chadha

The knee joint being a weight-bearing joint, stability is vital for any individual’s day-to-day mobility. The human body has more than 150 joints and the joint most commonly afflicted by injury/disease is the knee joint.

Knee pain can be at the front, back or at the inner or outer sides of the knee joint.

Young people are vulnerable to pain on the front side of the knee joint which could be due to the lack of coordination between the muscles (especially quadriceps) and patella/kneecap. Old people commonly complain of pain on the inner side of the knee joint due to decreased joint space.

The pressure/force exerted on the knee-cap ranges between one-third and one-half of a person’s body weight during walking, around three to four times body weight when climbing stairs and up to seven times during squatting.

Women are more prone to knee pain as their usually wider hips alter the angle with the knee joint, putting more pressure on the inner side of the knee joint.

The treatment of most of the knee problems is conservative.

l Early treatment involves icing, wrapping with crepe bandage and elevation to reduce pain and swelling.

l Body weight control. Obesity is a major factor for the knee problem. One pound of weight puts six times more stress on the knee.

l Knee braces/sleeves.

l Non-impact conditioning like walking/stationary cycling, swimming, etc.

l Sports shoes which can absorb impact shock. In case your shoes are worn out, it is better to change them which can absorb the shock. Normally a person should change shoes every four-six months.

l Glucosamine sulfate 1500 mg/day builds joint lubrication/cartilage.

l Injection of hyaluronic acid — A series of three to five injections weekly lubricate the knee joint in a natural way.

Injection helps the arthritis surface to glide more smoothly.

Rehabilitation exercise programme for the knee joint pertains to treatment with regaining coordination of the joint through stretching and strengthening exercises. The aim of rehabilitation is:

To strengthen the muscles involved in the injury.

To regain power and coordination of the knee joint movement.

To regain the range of motion of the knee joint.

The only thing which holds the knee in position is muscles and ligament. Therefore, it is important to build up the muscles; otherwise the knee becomes unstable and liable for injuries. Strong muscles can withstand strain, thereby putting less pressure on the knee. People with weak leg muscles feel discomfort while climbing stairs.

Warming up with five minutes of low-impact aerobics such as walking or riding a stationary exercise bike increases blood supply to the muscles to help prevent injury and stiffness.

The common exercises useful for managing any knee pain are as under:

l Knee flexion: This exercise improves the mobility of the knee joint. Pull the heel towards the buttocks as much as possible without using hands. Then clasp the shin with both hands and pull the heel towards the buttocks and hold. Use a towel if unable to grasp your shin with hands. Repeat 10 times.

l Sitting in a chair extend your legs with heels to the floor. Keeping knees straight, tighten thigh muscles. Hold for a count of 10 and relax. Repeat 10 times several times a day.

l Straight leg rise: This exercise helps strengthen the front muscle of the thigh — quadriceps. Sitting against a wall with a pillow at the back, raise the injured leg off the ground at about 45-degree angle. Stay on for a count of 10. Repeat 10 times. Ankle weight can be added to the increase resistance.

l Knee press — This exercise helps in stretching and strengthening quadricep muscles. Sit on the floor. Place a small pillow or rolled up towel below the knee. Press it for a count of 10 and relax. Repeat it 10 times.

l Hamstring stretch — Lie on your back. Raise one leg. Grasp the back of the knee with hands. Pull the leg towards the chest. Hold for a count of 15. Repeat if five times.

To conclude, one should undergo proper rehabilitation for any knee pain; otherwise it can lead to early osteoarthritis and disability of the knee joint.

The writer runs a pain management clinic in Chandigarh. E-mail: chadha_r2003@yahoo.co.