Questions answered in this video include:

1. What are the methods for dietary management for a person with diabetes?
2. How does someone who is diagnosed with diabetes prevent long-term complications, mainly damage to blood vessels?
3. What do you do when you are eating at a restaurant and are not aware of the amounts of saturated fats?
4. Is exercise suggested for an individual with diabetes?

Notes on Maudene Nelson, MS, RD, CDE:

Maudene Nelson is a nutritionist (registered dietitian) and a certified diabetes educator. Since 1975 Ms. Nelson has been a nutritionist and instructor at the Institute of Human Nutrition, Columbia University and the Arteriosclerosis Research Center, New York-Presbyterian Medical Center. At New York-Presbyterian she has provided nutrition counseling to patients, co-authored several publications and taught medical, nursing, public health, and graduate nutrition students.

Ms. Nelson received her B.S. in Human Nutrition in 1971 from Cornell University and her M.S. in Public Health Nutrition from Teachers College, Columbia University in 1976. She has been a volunteer and consultant to the American Heart Association and the American Diabetes Association.

Ms. Nelson also provides nutrition counseling and conducts nutrition workshops for employees in the Corporate Wellness and Fitness Services at the Metropolitan Life Insurance Company and the Employee Health Care Services at Merrill Lynch in the World Financial Center.

-Adapted from Ms. Nelson’s biography featured on Healthology.org

-Read an article on diabetes by Ms. Maudene Nelson

Questions answered in this video include:

1. What is Alzheimer’s Disease?
2. Is Alzheimer’s Disease the same as Dementia?
3. How common is Alzheimer’s Disease in Canada?
4. What changes are seen in the brains of patients with Alzheimer’s Disease?
5. Is there a genetic component to Alzheimer’s Disease?
6. What are the risk factors for developing Alzheimer’s Disease?
7. What are some of the treatment options available to individuals with Alzheimer’s Disease?
8. What other possible treatment options are currently being explored by researchers?

Notes on Dr. David Westaway:

Dr. David Westaway is an internationally acclaimed researcher and director of the Alberta Centre for Prions and Protein Folding Diseases at the University of Alberta. Here,  he has become one of two inaugural Prion Institute Scholars. The scholar program was recently established by the Alberta Prion Research Institute, which funds research into the prevention and management of prion-related diseases, like Alzheimer’s and Parkinson’s disease.

Previously a researcher with the Centre for Research in Neurogenerative Disease at the University of Toronto, Westaway is a molecular biologist who completed his postdoctoral training at the University of California with Nobel laureates Harold Varmus and Stanley Prusiner, where he helped to define the molecular biology of prion diseases. His work on cellular prion protein and two related proteins has led to insights about Alzheimer’s disease.

Most neurodegenerative diseases like Alzheimer’s disease are protein-folding diseases. These diseases are caused by prions, a type of protein which causes neurodegenerative diseases when they fold incorrectly. This field of study is relevant to the public on many levels. Prion research is an “enormously practical problem on a very day-to-day level with an impact on agriculture,” says Westaway. Prion diseases are also critical to human health and “some of the tools of prion research have been put to good effect in neurodegenerative diseases that are common in humans.”

-adapted from an article on the website of “Canadians for Health Research

Alzheimer’s Disease:

Dementia can be defined as a serious loss in cognitive ability attributed to factors beyond natural aging. Alzheimer’s disease is the most common form of dementia; affecting an individual’s memory, cognition and behaviour. Currently the incidence rate of Alzheimer’s disease in Canada is approximately 1 in 11 individuals over the age of 65, making Alzheimer’s disease a common disease amongst senior citizens. While Alzheimer’s disease is currently an incurable disease, and treatment options mainly focus on the management of the disease, a significant amount of research is being performed in order to learn more about this complex disease and hopefully develop more advanced treatment techniques.

Pathophysiology

The pathophysiology of a disease is basically describing the abnormal changes occurring in the body that causes the symptoms experienced in patients with that particular disease. As such, the pathophysiology of Alzheimer’s disease will describe what is happening in a patient’s brain as the disease progresses (however it may not describe what causes these changes to occur). Alzheimer’s disease is characterized by the loss of neurons (brain cells) and the connections between neurons (known as synapses). This results in the deterioration of various parts of the brain, including the parietal and temporal lobe, as well as parts of the frontal cortex. The deterioration of these areas of the brain leads to the symptoms experienced by patients with Alzheimer’s disease (including memory loss, loss of cognition, etc.). The exact cause of this deterioration is not well understood however, an increased number of substances called amyloid plaques and neurofibillary tangles are noted in the brains of patients who have Alzheimer’s disease.  Amyloid plaques are insoluble protein structures that form around the brain cells, while neurofibrillary tangles are incorrectly developed proteins (Tau proteins) that accumulate inside the brain cell. As you may notice, both amyloid plaques and neurofibillary tangles are forms (or mis-forms) of proteins. As such, Alzheimer’s disease has been identified as a protein mis-folding disease caused by the accumulation these abnormally formed proteins.

The cause of the proteins accumulating in and around the brain cells of Alzheimer’s patients is not yet fully understood, however mutations in several genes have been identified as events leading to the protein accumulations. As genes serve as the ‘instructions’ for the construction of proteins in the body, genetic mutations could give rise to the formation of proteins that can interfere with the normal functioning of the body. With regards to Alzheimer’s disease, mutations of the APOE gene has been found cause the symptoms associated with Alzheimer’s disease, with individuals carrying this genetic mutation having an increased chance of being diagnosed with Alzheimer’s disease. The other possible genetic links are not as clear, but current research is looking into further identifying the mutations and genes that can lead to the protein mis-folding seen in patients with Alzheimer’s disease.

Causes and Symptoms

The exact cause of the disease is not fully understood, but there are several theories that attempt to explain certain aspects of the disease. One theory is that Alzheimer’s disease is caused by a deficiency in the neurotransmitter acetylcholine. A neurotransmitter is a molecule that neurons (brain cells) use to communicate with other cells in the body. According to this postulate (“theory”), the deficiency in acetylcholine is the primary cause of the cognitive impairment seen in patients with Alzheimer’s disease. Many current drug treatments are based on this theory however several other researchers have proposed different postulates to explain the cause of Alzheimer’s disease. One of these alternative causes focuses on how genes play a role in Alzheimer’s disease. The influence of the APP gene and APOE4 gene are thought to cause excess amyloid plaque build-up and account for the neuron death and cognitive impairment seen in patients with Alzheimer’s disease. Finally, the “tau hypothesis” proposes that abnormalities with the tau proteins present in the human body that result in the tau molecules clumping together and forming neruofibrillary tangles, strongly correlates with the cell death seen with Alzheimer’s disease.

Whatever the cause, it has been found that the damage to the brain starts about 10 years before the initial onset of symptoms. During this time, the connections between neurons in the brain become weak and ineffective at transmitting impulses that are needed for the full function of the brain. As the connections are slowly lost and the neurons die, parts of the brain become weaker and symptoms can begin to appear. For instance, when the neurons begin to weaken and die in an area of the brain called the Hippocampus, memory loss starts becoming apparent. In fact, severe memory loss is often an early symptom of Alzheimer’s disease, however it should be noted that memory loss can be a symptom associated with a variety of other disease as well. Other early symptoms of Alzheimer’s disease include a decline in cognitive ability, including difficulty in tasks requiring visual/spatial skills as well as impaired reasoning and judgement.

As the disease progresses, a number of routine daily activities will become increasingly difficult, such as speaking (due to a decrease in vocabulary) and tasks requiring motor skills (ie: tying a shoe, getting dressed). In addition, the neurological effects will become increasingly more profound, leading to possible delusions, personality and emotional changes, and losing the awareness of one’s condition and environment.

In the final stages of the disease, the patient will be fully dependant on a caregiver and may lose their ability to communicate verbally (however they can still hear and interpret messages), eventually lose the ability to independently eat and drink (due to decreased muscle mass) and become more fatigued and tired. While Alzheimer’s disease is a terminal disease, the more common cause of death for Alzheimer’s patients is due to external factors, such as infections or pneumonia.

Treatment

As previously mentioned, current treatment options focus mainly on the management of symptoms rather than the treatment of the disease. The two main types of medications used to manage the symptoms of Alzheimer’s disease are Acetylcholinesterase inhibitors and memantine.  Acetylcholinesterase inhibitors are often used to manage mild to moderate Alzheimer’s disease by blocking the acetylcholine neurotransmitter. The most common side effects of this treatment are nausea and vomiting. Memantine is a NMDA receptor antagonist and works by blocking the action of the NMDA receptors (which respond to the neurotransmitter glutamate). This treatment has shown to be effective in treating moderate to severe Alzheimer’s disease. Side effects of memantine include hallucinations, confusion, dizziness, headaches and fatigue.

Other non-medicinal treatment options may be effective at managing Alzheimer’s disease including the use of emotional intervention methods. Methods of emotional intervention include using reminiscence therapy and sensory integration. Reminiscence therapy is performed by having the patient recall different memories from their past sometimes utilizing memory aids such as pictures. This therapy may be used to help with cognition and mood. Sensory integration is performed by altering the patient’s surrounding by including differ objects that are both soothing and stimulating to one’s senses (such as lava lamps). This type of room is often called a snoezelen room and is also used as a sensory therapy for other mental disorders. While little scientific research has been performed to determine the effectiveness of these therapies, there may be some evidence that these therapies can help with the patient’s mood and emotions.

It is also essential that a patient with Alzheimer’s disease has adequate care from a caregiver, as during the final stages of Alzheimer’s disease, many normal functions (such as eating) will be hard to perform without assistance. In addition, the caregiver is able to provide emotional support for the patient, further necessitating a caregiver for the individual.

Some researchers are also looking into how certain lifestyle changes/activities could prevent or delay the onset of dementia or Alzheimer’s disease. Examples of recommended changes/activities include preforming activities that engage the brain (such as playing games or learning a new skill), keeping physically active and eating a healthy diet that is supplemented with Omega 3 fatty acids (found in fish and certain nuts). While there is not conclusive evidence on whether these lifestyle factors can help those who may develop Alzheimer’s disease, all these factors presented have shown to be effective in helping with certain chronic diseases such as heart disease, type II diabetes and obesity. Therefore, on the advice of a physician, it is recommended that at least some of these lifestyle actions be included in some aspect of the individual’s daily routine (especially if they are a senior citizen) for the prevention of a variety of chronic diseases, and also to possibly prevent or delay the onset of Alzheimer’s disease or dementia.

Current Research

Currently, there is a large amount of studies being conducted in order to better understand and find an appropriate treatment for Alzheimer’s disease. While extensive research is being conducted on many aspects of Alzheimer’s disease, two research areas that were recently highlighted include research into potential biomarkers of Alzheimer’s disease and the possibility of creating a vaccine for Alzheimer’s disease.

In a recent research article published in Nature (July 14, 2011), the possibility of using ‘biomarkers’ to help doctors identify patients who may develop Alzheimer’s disease was explored. Biomarkers are biological indications (ie: genes types, proteins in the blood, etc.) whose presence could indicate the patient’s susceptibility to developing particular diseases. Discovering biomarkers for Alzheimer’s disease would help doctor’s diagnose the disease before symptoms appear and help researchers develop a effective drug that can prevent the onset of the disease. At the University of Pennsylvania’s Alzheimer’s Disease Center, hundreds of thousands of blood and cerebral spinal fluid (the fluid that exists in your brain and spine) samples are stored and made available to researchers who are looking into Alzheimer’s disease. These samples along with high-resolution brain scans are vital sources of information for the Alzheimer’s Disease Neuroimaging Initiative, an organization that is devoted to Alzheimer’s research and specifically, identifying potential biomarkers. Currently, research has shown that the presence of a certain amyloid protein or an elevated total level of tau protein could be used to determine an individual’s susceptibility to developing Alzheimer’s disease; with the presence of a special form of tau protein (with additional phosphate groups) serving as the most effective biomarker . Researchers studying biomarkers are hopeful that further tests will show that these biomarkers are accurate and effective at determining ones likelihood of developing Alzheimer’s disease and could soon become standard medical tests that a doctor could perform on an individual who is at risk of developing Alzheimer’s disease.

Some researchers are also exploring the possibility of developing a vaccine for Alzheimer’s disease.  The main goal of a vaccine for Alzheimer’s disease is to utilize the body’s own immune system to attack and destroy the mis-formed proteins that cause the symptoms, such as amyloid proteins. While previous trails of a vaccine did not turn out very promising, recently a group of researchers have found that administering IVIg (intravenous immunoglobulin) to a group of Alzheimer’s patients was effective at improving or stabilizing their symptoms.  IVIg is a treatment that is often used to boost immunity in a patient whose immune system is compromised (often due to genetic reasons or certain diseases). Drug trails are currently being performed on the use of IVIg in the treatment of Alzheimer’s disease and the results could be made available by the end of 2012. One problem with using IVIg as a treatment for Alzheimer’s disease is that patients would require relatively high doses and there is a limited supply of IVIg (as it is obtained from donated blood). In addition, while IVIg has been shown to improve the symptoms in some Alzheimer’s disease patients, the effects are not permanent and can wear off within a couple of months. However, more research into alternative ways of developing and distributing a vaccine for Alzheimer’s disease is being conducted and some believe that an effective vaccine could be developed within the near future.

Links

Alzheimer Society of Canada – http://www.alzheimer.ca/

Alzheimer’s Disease Neuroimaging Initiative – http://www.adni-info.org/

References

“Alzheimer’s Disease Fact Sheet.” National Institute on Aging. July 2011. Web. 12 Sept. 2011. <http://www.nia.nih.gov/Alzheimers/Publications/adfact.htm>.

“Alzheimer’s Disease: Statistics.” Alzheimer Society of Canada – Société Alzheimer Du Canada. Web. 12 Sept. 2011. <http://www.alzheimer.ca/english/disease/stats-intro.htm>.

Schnabel, Jim. “Vaccines: Chasing the Dream.” Nature 475.7355 (2011): S18-19. Print.

Williams, Ruth. “Biomarkers: Warning Signs.” Nature 475.7355 (2011): S5-S7. Print.

Photo Credits

http://www.ahaf.org/alzheimers/about/

Questions answered in this video include:

1. What is Rheumatoid Arthritis?
2. What exactly causes Rheumatoid Arthritis?
3. Who is usually affected by rheumatoid arthritis, and what are some risk factors for getting it?
4. What are some signs and symptoms that might indicate an individual has RA?
5. Aside from the joint symptoms, what are some common systemic symptoms of RA?
6. How is the diagnosis of RA made?
7. Is there a single test that can indicate if a Patient has RA?
8. What are the current treatments available for RA?
9. Is this disease curable?
10. Would patients with RA have to remain on these treatments for life?
11. Are there any complications associated with RA?
12. Is there a possibility that some of these complications will improve with age?
13. Will Rheumatoid Arthritis improve with age, or is this something that will get worse?
14. If an RA patient receives appropriate treatment, will their life expectancy improve?
15. Are there any reliable online resources you would recommend for RA patients?

Notes on Dr. Janice Liao:

Dr. Janice Liao is a dermatologist specializing in hair transplantation, with over 25 years of experience in the field. Dr. Liao is the past president of the Alberta Society of Dermatology and board member of both the Canadian Dermatology Association and Canadian Society of Dermatological Surgery.

Background Information – Androgenic Alopecia:

Alopecia (balding) is a very common problem in both males and females. At age 50, about 50% of the male population will be affected by it. In females, around 30% of the population will experience balding to some degree by age 40. The exact amount of money spent yearly on treating alopecia is unclear, but figures suggest that it is a multibillion dollar industry. Alopecia can be caused by genetic factors, medication (e.g. chemotherapy), and nutritional deficiencies such as a lack of iron. Many types of alopecia occur in humans, such as traction alopecia, alopecia areata, scarring alopecia and androgenic alopecia. Androgenic alopecia, commonly known as male pattern baldness, contributes to the vast majority of hair loss seen in both males and females and is caused predominantly by genetic factors.

Pathophysiology:

Male pattern baldness (MPB) typically begins with a receding hairline, slowly becoming an “M” shape, sometimes referred to as a widow’s peak. The hair on the crown then begins to thin out, along with other existing hair at the frontal hairline. Depending on the severity, the top of the head may eventually become completely bald, leaving a horseshoe-shaped bald patch. Characteristically, MPB spares the lateral aspects of the scalp, leaving a ring of hair follicles resistant to hair loss along the sides of the head. This is due to a lack of receptors on these hair follicles to the androgen DHT, which causes hair loss in hairs at the back and side of the head.

This loss of hair is a completely physiological process, although it can commonly result in adverse psychological effects in an affected individual.

Male pattern baldness has been studied extensively, and it is evident that it is predominantly dictated by a few hormones and enzymes, the most influential of which is dihydrotestosterone, or DHT. This substance is created from another hormone called testosterone, of which approximately 5% is reduced by an enzyme called 5-alpha-reductase to produce dihydrotestosterone. DHT facilitates pubic and body hair growth during puberty, and a lack of this hormone can lead to a deficiency of body hair or more serious developmental abnormalities during normal male development. However, despite promoting hair growth and the development of male secondary sexual characteristics earlier in life, the role of DHT can curiously reverse and begin to promote hair loss in individuals with a genetic susceptibility and/or sensitivity to this hormone. The extent to which hair follicles on the scalp are sensitive to DHT determines the total extent of hair loss an individual will experience.

Thus, the genes that dictate the hormonal receptor’s response to DHT play a central role in the onset of androgenic alopecia. Studies had shown that a certain variant of androgen receptor is needed for male pattern baldness to occur. The genes responsible for this type of receptor are recessive (meaning one copy of the gene from each parent is required for it to work), and are located on the X chromosome.

Treatments:

One of the most widely used treatments for androgenic alopecia is a drug called finasteride (Propecia^TM, Proscar^TM). It is a synthetic substance that inhibits 5-alpha-reductase, the enzyme that converts testosterone to DHT. Studies have shown that this treatment can prevent further hair loss in up to 90% of the individuals, while a certain percentage of people may in fact experience hair regrowth. However, the effect of finasteride lasts only as long as it is taken, and therefore the pill must be taken long-term and on a daily basis for optimal results. Hairs grown or maintained through the use of finasteride are at risk of being lost within 6-12 months after treatment stops. Since this drug inhibits the production of DHT, a male sex hormone, adverse side effects may include erectile or ejaculatory dysfunction and decreased libido. A few European agencies have warned of permanent sexual dysfunction, and this warning is included on the European product label but not North America warning label. Importantly, this drug should also not to be handled or ingested by pregnant and breastfeeding women, or by women planning on becoming pregnant soon. Additionally, it is recommended that males who intend to try to conceive a child with their partner should cease taking finasteride for a period of at least 3 months. In all, though, this medication is very well tolerated by the majority of patients, and it is the most effective medical treatment option currently available for MPB.

Minoxidil (or Rogaine^TM) is another popular treatment option for androgenic alopecia. Originally developed for high blood pressure, the side effect of increased hair growth in patients soon led to its adoption as a hair loss treatment option. Topical minoxidil is made specifically for treating hair loss. It often comes in the form of a liquid or foam in both a 2% and 5% concentration, and is directly applied to the scalp once or twice each day. The exact mechanism of how minoxidil works is still unknown, but its effect is thought to be related to increased blood flow and oxygenation to the scalp. As with finasteride, treatment should be maintained long-term for optimal results, as hair loss will resume after minoxidil is discontinued. Minoxidil can be used to treat male pattern baldness in both men and women, and can in fact produce more pronounced results in the latter. The side effects of minoxidil may include local skin irritation and flaking, although in general this medication is very well tolerated by patients. A sometimes bothersome secondary side-effect is the unsightly flaking of the liquid preparation of this medication when applied to the scalp. In this circumstance, flaking can often be minimized by switching to the foam preparation.

For individuals who have failed medical therapy for MPB and in those patients for whom hair loss is particularly psychologically distressing, the next and most definitive treatment option is hair transplant surgery. This surgery involves transplanting small areas of hair follicle-containing skin, harvested from the peripheral areas of the scalp where follicles tend to be resistant to hair loss, to areas of the scalp where hair loss has occurred. Though the transplanted hair will not be as dense as it was prior to when hair loss first occurred, a properly done re-distribution of resistant scalp hair can significantly reduce the effects of MPB on a patient’s overall cosmesis. Side effects may include continued thinning of hair, scarring, and a small risk of skin infection. Importantly, it is important that patients maintain a strict regimen of additional hair loss-prevention measures (namely minoxidil and/or finasteride therapy) after the procedure has been completed, to prevent continual loss of non-resistant hair follicles.

Research:

Currently, there are several exciting avenues of research being explored in the field of male pattern hair loss. Of these, the most cutting-edge and potentially most promising is the harvesting and growth of stem cells into new, fully functional hair follicles, which would then be surgically implanted into the scalp in much the same manner as hair transplant are currently conducted. If this technology is brought to fruition, stem cell-based hair transplantation would mitigate the limiting factor affecting our current transplant technology, namely the availability of viable, resistant hair follicles.

Questions answered in this video include:

1. What is skin cancer?
2. How does a skin tumor develop, and what processes are involved?
3. Are there different forms of skin cancer?
4. What are some specific types of Non-melanoma skin cancers (NMSC’s)?
5. How common are NMSC’s in society?
6. Of the BCC and SCC, which is more commonly found?
7. Do certain segments of the population have a higher risk of developing NMSC’s?
8. Do artificial tanning beds increase your risk of developing skin cancer?
9. Can people from any age group develop an NMSC, or are certain ages more prone?
10. What features or aspects of the skin might lead a specialist to suspect a BCC or SCC?
11. Are there warning signs that allow skin cancers to be detected early?
12. What are some potential consequences of a BCC that goes unchecked for a long period?
13. What are some dangers of leaving a SCC unchecked for a long period?
14. Is there anything patients can do to prevent these types of skin cancers?
15. What treatment options are available to someone who is diagnosed with an NMSC?
16. What is Mohs Micrographic Surgery?
17. How does Mohs Micgrographic Surgery differ from regular surgical excisions?
18. After receiving treatment for a BCC or SCC, what are the chances of the tumor reappearing or recurring?
19. Are there any other long-term complications that can arise after treatment?

About Dr. Taher

Dr. Taher completed his dermatology training at the University of Alberta. Prior to this, he underwent fellowship training in Moh’s micrographic surgery in Dermatologic surgery in Los Angeles and Santa Monica, California. While in the United States, he was on faculty at USC and also lectured at UCLA. Dr. Taher has an interest in general medical dermatology and cutaneous oncology and provides advanced skin cancer surgery skills to his patients.

Read about Dr. Taher’s innovative skin cancer screening and treatment clinic for organ transplant patients

Keystone Dermatology Institute

Nonmelanoma Skin Cancer – Backgrounf Information

Skin cancers are abnormal growths of the skin that have many possible etiological factors and varying degrees of severity. There are two major categories of skin cancer, namely melanoma and non-melanoma skin cancers (NMSCs). Of the non-melanoma skin cancers, the two most common types are squamous cell and basal cell carcinoma. Together, they make up about three quarters of all NMSCs, and are the most commonly diagnosed of all human cancers.  The squamous and basal cells are cells that make up the epidermis, or the outmost layer, of the skin. The squamous cells are the mature cells that gradually move toward the surface of the skin, and basal cells are the infant stage cells being constantly produced deeper in the epidermis, pushing the squamous cells upwards.

Pathophysiology:

Basal cell carcinoma (BCC) is most commonly found on skin that’s been exposed to the sun, with 80% occurring on patients’ face and neck. It usually has the appearance of a smooth, shiny bump on the skin. Sometimes the bump is translucent in nature, and blood vessels can be seen. Some types of basal cell cancers can resemble a thickening of skin or scar tissue. It should also be noted that it is difficult to differentiate between basal cell carcinoma and acne scars, amongst other skin conditions. This type of carcinoma is the most common type of skin cancer, with a person’s lifetime risk of developing BCC around 30%. Luckily, BCC is one of the most treatable forms of skin cancer, with metastasis or death occurring in only extremely rare instances. Nevertheless, uncontrolled proliferation of BCC has the potential to cause substantial local tissue destruction, and thus prompt treatment and careful follow-up is very important.

There are a few primary etiological factors which have been identified that lead to the development of basal cell carcinoma. It has been observed that certain genetic traits, namely Caucasian traits, such as light colored skin, blue or green eyes, and blonde or ginger hair can elevate the risk for basal cell skin cancer. Also, overexposure to strong radiations such as ultra violet and X-ray radiation also increases the risk for this type of skin cancer. As with all cancers, genetic pre-disposition is also a major factor. Early signs and symptoms that may indicate the presence of basal cell carcinoma includes a sore on the surface of skin that bleeds easily and refuses to heal, or the emergence of a scar-like sore in an area that has not previously been injured.

Squamous cell carcinoma (SCC) occurs less commonly than basal cell carcinoma, although it does still make up a significant proportion of the overall skin cancer burden. It appears as a growing bump that may take on different textures and colors. Commonly, it presents as a reddish, scaly papule which may have a rough of crusty surface. It is also most prevalent in areas on the face or neck, as well as other areas that are exposed to the sun. Patients commonly describe SCC as having a sore which doesn’t seem to heal. This type of cancer can also occur in organs other than the skin, including lung, liver, prostate, cervix, etc. Appearances and symptoms of the cancer may vary with the organ.

Squamous cell carcinoma can be caused by a variety of different environmental factors. It tends to appear in individuals with lighter skin and those who have been overexposed to X-ray and ultra violet radiation. Risks for this cancer are also higher in individuals who have had contact with environmental toxins such as arsenic. Old age is itself a risk factor for SCC development. Finally, another important risk factor for the development of SCC is immunosuppression, such as is the case with organ transplant recipients who receive lifelong immunosuppressive therapy to lower the chances of tissue rejection. Thus, patients such as this require close monitoring and regular skin check-ups performed by a dermatologist.

Treatments:

To determine whether the case is indeed skin cancer, a biopsy will is usually performed in which a small piece of skin tissue is removed for further examination in a laboratory. Basal cell skin cancers are relatively easy to treat, and the rate of recurrence is under 10%; squamous cell skin cancer can be cured with a high success rate if discovered and treated promptly. However, compared to BCC, SCC is somewhat more likely to recur locally and is also associated with a slightly higher chance of distant metastasis.

Many treatments are currently used to treat skin cancers. These include surgical excision, Mohs micrographic surgery, curettage and electrodesiccation, radiation therapy, and skin creams. Doctors will recommend and employ different treatment methods depending on the size and location of the tumor, age of the patient, and other factors which may result in a specific treatment modality being indicated.

Surgical excision, including Mohs micrographic surgery, is the preferred method in dealing with most skin cancers. This method results in removal of the tumor and results in the lowest rates of local recurrence and metastasis. Due to the limitations of conventional surgical removal in cosmetically sensitive or high risk areas such as the face, Mohs smicrographic surgery is often the preferred choice. This type of surgery removes a thin layer of skin cancer, which is immediately examined under a microscope to check for cancer cells. The base and side of the sample is specifically assessed, and the surgeon will then continue to remove layers of skin until the sample observed is free of cancer cells. This method allows for maximal tissue sparing, lower recurrence rates and a higher degree of confidence that all of the cancer has been removed.

The curettage and electrodesiccation method is often used for tumors of smaller size and in non-cosmetically sensitive areas. This method uses a curette to scrape away the tumor, before an electric current is applied to further eliminate any remaining cancer cells. The cure rate is highly varied and depends on the size and type of the tumor.

Radiation therapy (RT) involves utilizing damaging radiation to destroy cancer cells. The normal tissues around the tumor are also be affected to some degree, and thus a recovery period is needed in between treatments to allow for healing. The resting period does not allow the cancer to recover much since the cancer cells are not as apt at restoring themselves. Radiation therapy is used when cancer has spread to other organs or lymph nodes and surgical removal would be difficult. Fragile areas that are difficult to reconstruct (i.e. nostril rim) are also sometimes treated by radiation therapy. RT is also used for elderly patients that are not well-suited for surgery. It takes multiple visits to complete the treatment, and can require anywhere from 5 to 25 visits. Radiation therapy can deliver a high success rate in curing tumors, although the exact cure rate depends on the type of tumor in question as well as its stage of progression.

Skin cream that contains imiquimod or 5-fluorouracil is used to treat superficial skin cancers. It is reported that such treatment is very effective in reducing and even removing the tumor, although marked inflammation often occurs as a side effect when using this treatment. This method is often used in conjunction with Mohs surgery to ensure the complete removal of the tumor.

Research:

A synthetic inhibitor of the Hedgehog Pathway that is known to induce tumor growth is currently under active investigation. This inhibitor is known as GDC0449, developed by the Curis Inc. and is currently under clinical trials by the Genetech company. It has been shown to slow or even stop the development of tumors, and can cause existing tumors to shrink. It does not only work on skin, but other organs such the esophagus and cervix as well.

References:

Canadian Cancer Society

http://www.cancer.ca

National Library of Medicine

http://www.nlm.nih.gov

Questions answered in this interview include:

1. What factors can result in an unhealthy fetus?
2. How does alcohol affect the health of a fetus? What about smoking?
3. Can medications negatively affect fetal health?
4. Should certain activities be avoided during pregnancy?
5. Can a mother’s health impact fetal well-being?

Dr. Nestor Demianczuk is a faculty member in the department of Obstetrics and Gynecology at the University of Alberta. His clinical practice and research interests focus on maternal-fetal medicine, and he has published a large body of scientific articles on the topic of fetal development.

For more information on fetal well-being and other pregnancy-related topics, you can visit the following credible websites, suggested by Dr. Demianczuk:

1. Society of Obstetricians and Gynecologists of Canada
2. American College of Obstetricians and Gynecologists
3. MOTHERISK : information on medication use during pregnancy
4. Center for Disease Control and Prevention (CDC)

Questions answered in this interview include:

1. How is fetal well-being defined?
2. What strategies are used to assess fetal health during pregnancy?
3. What are some of the indicators used by physicians to determine the health of a fetus?
4. What are some examples of developmental abnormalities which can be detected during fetal assessment?
5. During what stage of pregnancy are malformations most likely to develop?

Dr. Nestor Demianczuk is a faculty member in the department of Obstetrics and Gynecology at the University of Alberta. His clinical practice and research interests focus on maternal-fetal medicine, and he has published a large body of scientific articles on the topic of fetal development.

For more information on fetal well-being and other pregnancy-related topics, you can visit the following credible websites, suggested by Dr. Demianczuk:

1. Society of Obstetricians and Gynecologists of Canada
2. American College of Obstetricians and Gynecologists
3. MOTHERISK : information on medication use during pregnancy
4. Center for Disease Control and Prevention (CDC)

Some questions answered in this video are:

1. What should a person do if they see blood in their stool or vomit?
2. Does the amount of blood affect the proper course of action?
3. What are some causes of Upper GI bleeds?
4. What are some causes of Lower GI bleeds?
5. What are the two types of bloody stool?
6. What is Melena?
7. What is Hematochezia?
8. Why is Melena darker than blood from a Lower GI bleed?

Notes on Dr. Liu:

Dr. Liu joined the Faculty of Medicine and Dentistry at the University of Alberta in 2006. She joined the Division of Gastroenterology to promote endoscopic research activities. She is a recipient of a number of awards, research fellowships and grants including the Research Excellence in Gastroenterology And Liver Diseases (REGAL), and the Harvard center for minimal invasive surgery fellowship.

Dr. Liu’s research interest is in the anatomic and physiologic consequences of endoscopic anti-reflux therapy; her research in this area is supported by a grant from the Canadian Association of Gastroenterology(CAG)/CIHR grant. Her new research focuses on understanding intestinal permeability and cellular shedding using confocal endomicroscopy.

Dr. Liu has authored and co-authored over 30 scientific papers. She has contributed to a number of book chapters. She currently serves on a number of committees of gastroenterological societies, and is a reviewer for a number of journals including the Annals of Internal Medicine, American Journal of Gastroenterology and GI endoscopy.

Gastrointestinal Bleeding – Background Information

Being one of the most common symptoms that can lead to a patient being hospitalized, Gastrointestinal Bleeding (GI Bleeding) can be indicative of a serious medical condition. GI Bleeding describes any bleeding that originates from a location in the gastrointestinal tract, which spans from the throat to the rectum.  Generally, GI Bleeding is classified into Upper and Lower Gastrointestinal Bleeding. The causes and treatments can vary considerably between Upper and Lower GI Bleeding and as such, each will be explored separately.

Upper GI Bleeding

An Upper GI Bleed is classified as any bleed (hemorrhage) occurring along the gastrointestinal tract originating from the throat to the ligament of Tritez (located beyond the stomach in the small intestine, approximately between the duodenum and jejunum). In the United States of America, the incidence of Upper GI Bleeding is 100 per 100,000 population per year and is approximately 4 times more common than Lower GI Bleeding, with males being affected more than females.

Common symptoms of Upper GI Bleeding include weakness, dizziness, fainting, vomiting of blood (hematemesis) and black stools (melena). Black stools is caused by the iron in the blood oxidizing, and thus turning black, as it travels through the GI tract. As such, black stool usually indicates that the blood has travelled a longer distance, and thus is more likely due to an Upper GI Bleed.  However, with serious Upper GI Bleeding, the stool may sometimes appear red (hematochezia) due to the greater volume and speed of the blood traveling through the GI tract.

Causes

There are numerous causes of Upper GI Bleeding, ranging from chronic illness to acute stress. The most common cause of Upper GI Bleeding is Peptic Ulcer Disease, which is marked by the presence of gastric (stomach) and/or duodenal (first part of the small intestine) ulcers. In a general sense, ulcers are discontinuities in skin. If these breaks in the skin occur in the gastrointestinal tract, pain and bleeding can result. The risk factors for developing Peptic Ulcer Disease include excessive alcohol consumption, renal failure, and use of Non-Steroidal Anti-Inflammatory Drugs (NSAID).

Other common causes of Upper GI Bleeding include mucosal tears of the esophagus or fundus (Mallory-Weiss tear), Dieulafoy lesion (an arteriole located in the stomach wall that bleeds and erodes), and ulcerated gastric leiomyoma (large tumors that form in the stomach and small intestine). Furthermore, cancers of the esophagus (esophageal cancer) and stomach (gastric cancer) can present with Upper GI Bleeding. Gastritis (the inflammation of the lining of the stomach) can also lead to Upper GI Bleeding. Risk factors for developing gastritis includes excessive alcohol consumption, NSAID use and stress.

Treatment

The treatment for Upper GI Bleeding depends on both the cause and severity of the bleed. If the bleed is severe, the patient may first be administered intravenous fluids and blood products to ensure that the blood volume is stabilized. In addition, physicians may use quantitative determinants to assess risk of rebleeding, such as the Rockall score (which considers factors such as age and cause of the bleed).

In most cases, a physician will perform an endoscopy, as it can serve both as a diagnostic and treatment tool. For instance, in addition to giving the physician the ability to look inside the gastrointestinal tract, an endoscopy can also be used to directly administer medications and even repair bleeds.

In cases where Peptic Ulcer Disease is suspected, the patient will often be given an antacid or H2 antagonist (which limits acid production in the stomach). In addition, a gastroscopy (a type of endoscopy used to help confirm the presence of an ulcer), Urea breath test (to test for the presence of the H. pylori bacteria) or a stool antigen test may be performed to confirm the diagnosis of Peptic Ulcer Disease. Once an infection is confirmed, the patient may be given antibiotics and Proton-Pump Inhibitors (limits gastric acid production and aids in healing of bleeds in the stomach and intestines). Endoscopic surgery may be required to stop the bleeding if the bleeding caused by the ulcer is severe.

If the cause of the Upper GI Bleeding is found to be Gastritis, antacids will usually be given to help alleviate symptoms. If the antacids are ineffective at relieving the symptoms, medications may be prescribed including Proton-Pump Inhibitors (limits gastric acid production and aids in healing of bleeds in the stomach and intestines) and antibiotics (used to treat bleeding ulcers caused by the Helicobacter pylori bacteria). The risks associated with these medications largely depend on the extent of the bleeding and the condition of the patient.

A Mallory-Weiss tear usually heals without treatment, but if the bleeding fails to stop, surgical procedures such as clipping or epinephrine injections may be required. Similar surgical procedures serve as treatment options for patient who are found to have a Dieulafoy lesion.

If the bleed is found to be due to a ulcerated gastric leiomyoma or a cancerous tumor, a variety of treatment options could be recommended, including the surgical removal of the tumor, chemotherapy and/or other medications prescribed by an oncologist (physician specializing in the diagnosis and treatment of cancer).

Lower GI Bleeding

A Lower GI Bleed is classified as a bleed that originates in a location beyond the ligament of Tritez (the first part of the small intestine) to the rectum in the gastrointestinal tract. Lower GI Bleeding accounts for approximately 20-33% of all reported cases of gastrointestinal bleeding, with an incidence rate of approximately 20-27 per 100,000 population in the United States of America. While it is statistically not as common as Upper GI Bleeding, the number of cases of Lower GI Bleeding may be under reported due to the lower number of individuals seeking medical treatment for Lower GI Bleeds. However, some Lower GI Bleeds can indicate a serious medical condition and may require immediate medical attention.

Lower GI Bleeds can be classified into 3 categories based on the extent of the bleed:

-Massive Bleeding

-Moderate Bleeding

-Occult Bleeding

Common patient symptoms and histories, as well as possible causes associated with each bleeding category are outlined in the figure below.

Source: http://emedicine.medscape.com/article/188478-overview

As indicated by the above figure, the symptoms of Lower GI Bleeding can vary greatly depending on the location and underlying cause of the bleed. Generally speaking, the most common symptom of Lower GI bleeding is bright red or maroon colored stools (hematochezia). Often, red stools indicate a bleed on left side of the body (as the blood has had less time to travel through the GI tract) and maroon stools are indicative of a bleed on the right side of the body. While less common, black stools (melena) can also be a symptom of Lower GI bleeding.  In addition, Lower GI Bleeding may present with symptoms associated with blood loss, including weakness, dizziness and fainting. Abdominal pain and diarrhea may also be associated with a Lower GI Bleed.

Causes

There are many illnesses that can present with Lower GI Bleeding. The most common cause of Lower GI Bleeding presented by patients in a hospital is Diverticular disease. Diverticular disease is a condition that is characterized by the formation (Diverticulosis) and subsequent inflammation (diverticulitis) of tissue pockets on the outer tissue layer of the colon or small intestine. Risk factors for developing Diverticular disease include older age, a diet low in dietary fiber, high intake of red meat and connective tissue disorders. Diverticular disease normally presents with abdominal pain/bloating and diarrhea or constipation.

Inflammatory bowel diseases, including Crohn’s Disease and Colitis, may also present with Lower GI Bleeding. Inflammatory bowel diseases are conditions that cause the inflammation of the small and/or large intestines. Inflammation to segments of the Lower GI tract as a result of Crohn’s Disease is thought to be caused by the body’s immune system attacking the cells of the gastrointestinal tract. Inflammation that can be attributed to Colitis may be a result of infection (Infectious Colitis), autoimmune malfunction (Ulcerative Colitis) or lack of blood flow (Ischemic Colitis). Most cases of IBD present with abdominal pain, diarrhea, loss of appetite and fatigue.

Lower GI Bleeding can also be a symptom of Hemorrhoids.  Hemorrhoids are structures in the anal canal that aid in stool regulation that can become inflamed and bleed. Internal Hemorrhoids (ones located deeper inside the anal canal) can present with painless rectal bleeding, while external hemorrhoids can be both painful and cause rectal bleeding. Besides rectal bleeding, hemorrhoids may present with rectal itching.

Finally, gastrointestinal cancers of the lower intestines (ie: colon cancer) can also present with Lower GI Bleeding.

Treatment

Like Upper GI Bleeding, the treatment for Lower GI Bleeding depends on the cause and severity of the bleed. Often, physicians will first ensure that the patient’s condition and blood volume is stabilized (using IV fluids and blood products) before beginning any procedure. In some cases, the physician may insert a nasogastric tube through the patients nose and into their stomach and test the fluids for any evidence of blood, as this would indicate that the bleed is in fact an Upper GI Bleed and will require a different treatment. Complications associated with the insertion of the nasogastric tube are usually minor, including nose bleeds, sore throat or sinusitis.

Once the bleeding is stabilized and it is confirmed that the bleed is a Lower GI Bleed, a colonoscopy will commonly be preformed in order to deduce the cause of the bleed. Once the bleed is localized and the underlying cause determined, treatment options will vary depending on the diagnosis.

If the bleeding is due to Diverticular disease, a physician may use an endoscope to inject epinephrine or use metallic clips to close the bleed (depending on the severity of the bleed). Antibiotics may also be used to eliminate any bacterial infection that may have caused the inflammation. Finally, a diet rich in dietary fiber and low in processed and fried foods may help patients manage the disease.

If it is found that the patient may have a type of Inflammatory Bowel Disease, a variety of treatment options are available. Generally, a strong anti-inflammatory (ie: prednisone) is usually given to provide relief of symptoms and reduce inflammation. Antibiotics may also be administered to patients who are diagnosed with Crohn’s Disease (and in some case, ulcerative colitis), as they have been shown to be effective in the long-term management of symptoms. With severe cases of Inflammatory Bowel Disease, namely ulcerative colitis, the surgical removal of part/all of the colon may be recommended to provide relief of symptoms. Patients with Crohn’s Disease may also have this type of surgery preformed, however it is often not curative and can have a high reoccurrence rate.

Hemorrhoids can be treated both surgically and non-surgically. Often, hemorrhoids can be treated by increasing the patient’s intake of fluids and dietary fiber, as well as using analgesic drugs (NSAID) and bathing. If warranted, a physician may perform outpatient procedures such as Rubber band ligation (where a band is placed around the hemorrhoid, cutting off it’s blood supply and causing it to shrivel up) and Sclerothearpy (where a substance is injected into the hemorrhoid, causing the vein walls to collapse and the mass to shrivel up).  If less-invasive treatment options fail, surgery may be recommended. Surgical procedures include a Stapled Hemorrhoidectomy (surgically disrupting the blood flow to the hemorrhoid) and in severe cases, a Hemorrhoidectomy (surgically removing the hemorrhoid), the former being the recommended option in most cases due to the lower risks and faster recovery.

If it is found that a tumor (or polyp) is causing the Lower GI Bleeding, physicians will often run tests to determine if the tumor is benign or cancerous. Depending on the results of those tests, the tumor may be surgically removed or the patient may be started on a variety of cancer treatments (ie: chemotherapy, etc.).

Latest Research

Lisa L. Strate, Yan L. Liu, Edward S. Huang, Edward L. Giovannucci, Andrew T. Chan Use of Aspirin or Nonsteroidal Anti-inflammatory Drugs Increases Risk for Diverticulitis and Diverticular Bleeding Gastroenterology – May 2011 (Vol. 140, Issue 5, Pages 1427-1433, DOI: 10.1053/j.gastro.2011.02.004)

Background & Aims

Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have been implicated in diverticular complications. We examined the influence of aspirin and NSAID use on risk of diverticulitis and diverticular bleeding in a large prospective cohort.

Methods

We studied 47,210 US men in the Health Professionals Follow-up Study cohort who were 40–75 years old at baseline in 1986. We assessed use of aspirin, nonaspirin NSAIDs, and other risk factors biennially. We identified men with diverticulitis or diverticular bleeding based on responses to biennial and supplementary questionnaires.

Results

We documented 939 cases of diverticulitis and 256 cases of diverticular bleeding during a 22-year period of follow-up evaluation. After adjustment for risk factors, men who used aspirin regularly (≥2 times/wk) had a multivariable hazard ratio (HR) of 1.25 (95% confidence interval [CI], 1.05–1.47) for diverticulitis and a HR of 1.70 (95% CI, 1.21–2.39) for diverticular bleeding, compared with nonusers of aspirin and NSAIDs. Use of aspirin at intermediate doses (2–5.9 standard, 325-mg tablets/wk) and frequency (4–6 days/wk) were associated with the highest risk of bleeding (multivariable HR, 2.32; 95% CI, 1.34–4.02, and multivariable HR, 3.13; 95% CI, 1.82–5.38, respectively). Regular users of nonaspirin NSAIDs also had an increased risk of diverticulitis (multivariable HR, 1.72; 95% CI, 1.40–2.11) and diverticular bleeding (multivariable HR, 1.74; 95% CI, 1.15–2.64), compared with men who denied use of these medications.

Conclusions

Regular use of aspirin or NSAIDs is associated with an increased risk of diverticulitis and diverticular bleeding. Patients at risk of diverticular complications should carefully consider the potential risks and benefits of using these medications.

Kueiyu Joshua Lin, Sonia Hernández–Díaz, Luis A. García Rodríguez. Acid Suppressants Reduce Risk of Gastrointestinal Bleeding in Patients on Antithrombotic or Anti-Inflammatory Therapy. Gastroenterology – July 2011 (Vol. 141, Issue 1, Pages 71-79, DOI: 10.1053/j.gastro.2011.03.049)

Background & Aims

We investigated the effect of different prevention strategies against upper gastrointestinal bleeding (UGIB) in the general population and in patients on antithrombotic or anti-inflammatory treatments.

Methods

We performed a population-based, nested, case-control study using The Health Improvement Network UK primary care database. From 2000 to 2007, we identified 2049 cases of UGIB and 20,000 controls. The relative risk (RR) of UGIB associated with various gastroprotective agents was estimated by comparing current use (defined as use within 30 days of the index date) with nonuse in the previous year, using multivariate logistic regression.

Results

The adjusted RR of UGIB associated with current use of proton pump inhibitors (PPIs) for more than 1 month was 0.58 (95% confidence interval [CI], 0.42–0.79) among patients who received low-dose acetylsalicylic acid (ASA), 0.18 (95% CI, 0.04–0.79) for clopidogrel, 0.17 (95% CI, 0.04–0.76) for dual antiplatelet therapy, 0.48 (95% CI, 0.22–1.04) for warfarin, and 0.51 (95% CI, 0.34–0.78) for nonsteroidal anti-inflammatory drugs. The corresponding estimates for therapy with histamine-2–receptor antagonists (H2RAs) were more unstable, but tended to be of a smaller magnitude. In the general population, PPI use was associated with a reduced risk of UGIB compared with nonuse (RR, 0.80; 95% CI, 0.68–0.94); no such reduction was observed for H2RAs or nitrates.

Conclusions

PPI use was associated with a lower risk of UGIB in the general population and in patients on antithrombotic or anti-inflammatory therapy compared with nonuse of PPIs. The reduction in risks of UGIB was smaller in H2RA than in PPI users.

Colin Crooks, Tim Card, Joe West. Reductions in 28-Day Mortality Following Hospital Admission for Upper Gastrointestinal Hemorrhage. Gastroenterology – July 2011 (Vol. 141, Issue 1, Pages 62-70, DOI: 10.1053/j.gastro.2011.03.048)

Background & Aims

It is unclear whether mortality from upper gastrointestinal hemorrhage is changing: any differences observed might result from changes in age or comorbidity of patient populations. We estimated trends in 28-day mortality in England following hospital admission for gastrointestinal hemorrhage.

Methods

We used a case-control study design to analyze data from all adults administered to a National Health Service hospital, for upper gastrointestinal hemorrhage, from 1999 to 2007 (n = 516,153). Cases were deaths within 28 days of admission (n = 74,992), and controls were survivors to 28 days. The 28-day mortality was derived from the linked national death register. A logistic regression model was used to adjust trends in nonvariceal and variceal hemorrhage mortality for age, sex, and comorbidities and to investigate potential interactions.

Results

During the study period, the unadjusted, overall, 28-day mortality following nonvariceal hemorrhage was reduced from 14.7% to 13.1% (unadjusted odds ratio, 0.87; 95% confidence interval: 0.84–0.90). The mortality following variceal hemorrhage was reduced from 24.6% to 20.9% (unadjusted odds ratio, 0.8; 95% confidence interval: 0.69–0.95). Adjustments for age and comorbidity partly accounted for the observed trends in mortality. Different mortality trends were identified for different age groups following nonvariceal hemorrhage.

Conclusions

The 28-day mortality in England following both nonvariceal and variceal upper gastrointestinal hemorrhage decreased from 1999 to 2007, and the reduction had been partly obscured by changes in patient age and comorbidities. Our findings indicate that the overall management of bleeding has improved within the first 4 weeks of admission.

Links

Canadian Association of Gastroenterology – http://www.cag-acg.org/

American Gastroenterology Association – http://www.gastro.org/

Some Questions answered in this video are:

1. What is endoscopy?
2. What does endoscopic equipment consist of?
3. What is endoscopy useful for?
4. What are some commonly performed endoscopic procedures?
5. Are endoscopic procedures dangerous?
6. What are some of the complications that can arise in an endoscopic procedure?
7. What is aspiration pneumonia?
8. What might cause these complications?
9. What are the probabilities of these complications occurring?
10. What are some new advances in endoscopy?
11. What is capsule endoscopy?
12. Is it true that endoscopy can also be used to treat bleeds?
13. What are some new methods for treating bleeds endoscopically?

Notes on Dr. Liu:

Dr. Liu joined the Faculty of Medicine and Dentistry at the University of Alberta in 2006. She joined the Division of Gastroenterology to promote endoscopic research activities. She is a recipient of a number of awards, research fellowships and grants including the Research Excellence in Gastroenterology And Liver Diseases (REGAL), and the Harvard center for minimal invasive surgery fellowship.

Dr. Liu’s research interest is in the anatomic and physiologic consequences of endoscopic anti-reflux therapy; her research in this area is supported by a grant from the Canadian Association of Gastroenterology(CAG)/CIHR grant. Her new research focuses on understanding intestinal permeability and cellular shedding using confocal endomicroscopy.

Dr. Liu has authored and co-authored over 30 scientific papers. She has contributed to a number of book chapters. She currently serves on a number of committees of gastroenterological societies, and is a reviewer for a number of journals including the Annals of Internal Medicine, American Journal of Gastroenterology and GI endoscopy.

Endoscopy – Background Information

Endoscopy is a general term describing a way for physicians to look inside a patient’s body using a flexible tube with a camera attached to the end (known as an endoscope). In addition to providing images of the body, endoscopic procedures can be used to administer medicines and perform a variety of surgical procedures.

Endoscopy is usually performed if the physician wants to investigate areas inside the patient’s body, such as the respiratory tract, urinary tract and gastrointestinal tract. The endoscope is inserted through a natural body opening (ie: mouth) or a small cut. The user also has the ability to insert tools and other devices into the endoscope to perform surgical procedures, administer medications and take tissue samples. There are many different types of endoscopies, depending on where the procedure is taking place. In this video, the two main gastrointestinal endoscopic procedures discussed were gastroscopy (esophagogastroduodenoscopy) and colonoscopy. In a basic sense, a gastroscopy is used to investigate the upper gastrointestinal tract, while a colonoscopy is used to investigate the colon (large intestine).  Both procedures can be used to diagnosis and treat a variety of conditions and will thus be explored separately.

Gastroscopy

Indications

A gastroscopy is usually performed if a patient presents with symptoms that could indicate a problem in the upper gastrointestinal system. Symptoms that may indicate upper GI problems and may require endoscopic investigation include weakness, dizziness, fainting, vomiting of blood (hematemesis) and black stools (melena).

Procedure

In preparation for the procedure, the patient will be asked to not eat or drink anything for an extended period of time leading up to the procedure (usually fasting overnight). Once in the procedure room, the patient will be given a pain killer and sedative so that they patient will feel no pain during the procedure (and may not have any recollection of the procedure depending on the sedative used). In addition, a local anaesthetic may be administered into the patient’s mouth to suppress the gag reflex. A mouth guard will also be placed in the mouth to protect the endoscope and the patient’s teeth. An intravenous (IV) line may also be inserted into the patient’s arm to administer medications during the procedure.

The patient will be asked to lie on their left side and after the sedatives take effect, the doctor will begin the procedure by inserting the endoscope through the mouth and into the esophagus. Depending on what body part the doctor would like to observe, the endoscope can be advanced further through the upper gastrointestinal tract into the stomach and duodenum (first part of the small intestine). Air may be passed through the endoscope to enhance the image of the tissue under investigation.

If during the gastroscopy a problem is found (such as a polyp or ulcer), it may be treated during the procedure using a variety of tools. If the problem is a bleeding ulcer, it can be treated using small metal clips that are placed using a device that is passed through the endoscope. In addition, epinephrine (which can constrict blood vessels) can be directly administered using the endoscope. The goal of both of these treatments is to stop the bleeding. If a polyp or tumour-like mass is found, a biopsy can be performed using the endoscope. The tissue sample can then be tested to determine if it is cancerous and help determine the appropriate treatment for the mass.

Depending on the level of sedation, the patient may feel the endoscope pass through certain parts of the body and may feel bloated (due to the air that is passed through the endoscope). The patient will also have trouble swallowing during and shortly after the procedure as the local anaesthetic has limited the gag reflex. However, the test is quite short, usually lasting between 5-20 minutes.

Side Effects/Risks

One of the common side effects of a gastroscopy is feeling bloated (due to the air that is passed through the endoscope during the procedure). In addition, the patient may have a sore throat or dry mouth after the procedure. Both of these side effects often resolve themselves in a relatively short period of time following the procedure. Black stools, pain, fever, vomiting blood and difficulty swallowing are rare but serious side effects. If the patient experiences any of these symptoms after the procedure, they should contact their doctor or healthcare provider immediately.

Serious side effects associated with a gastroscopy are relatively uncommon, with an incidence rate of less than 1 out of 1000 people. Patients who were put under general anaesthetic during the procedure are at a greater risk of complications associated with the anaesthetic. Risks of a gastroscopy include apnea (not breathing), excessive sweating, difficulty breathing, bleeding (due to a perforation of an epithelium or biopse), low blood pressure, low heart rate, and laryngeal spasms. The risks and complications of this procedure should be outlined in greater detail by a physician before the procedure takes place.

Colonoscopy

Indications

A colonoscopy is usually recommended for patients who present with symptoms related to gastrointestinal bleeding (particularly lower gastrointestinal bleeding) such as black or red stools, weakness, dizziness, fainting, anaemia (low iron – can be a result of blood loss), abdominal pain, significant changes in bowel habits and diarrhea. In addition, a colonoscopy is used as a screening procedure to detect cancers of the colon and rectum. In fact, the American Cancer Society recommends that men and women over the age of 50 should be screened for colorectal cancer and polyps using various screening methods; one option being to have a colonoscopy preformed every 10 years.

A colonoscopy is not recommended for patients who have significant inflammation of the lower intestines (that can be a result of conditions such as Crohn’s Disease or Inflammatory Bowel disease), due to the risk of perforating the colon.

Procedure

In preparation for the procedure, the patient’s intestines must be fully emptied. In order for this to occur, the patient will be asked to not eat solid foods for several days preceding the procedure and may be given enemas and/or laxatives. In addition, the patient will be encouraged to drink “clear fluids” (ie: water, sports drinks, soup broth, black coffee, etc.) in the days preceding the test. Liquids that contain fibre, such as milk and certain types of fruit juice should be avoided, as well as dietary products that are dyed (ie: red fruit punch) or can affect the physicians clear view of the colon (such as iron supplements). Finally, the patient may be asked to refrain from using Asprin and other particular pain killers due to the increased risk of intestinal bleeding. On the day before the test, the patient may be given additional laxatives to fully cleanse the gastrointestinal tract.

When it is time for the procedure, that patient will be asked to lie on their left side in a position similar to a fetal position. A pain killer and sedative will usually be given and the physician will perform a rectal exam to ensure that the colonoscope can be properly inserted. After the rectal exam, the colonoscope is inserted through the rectum and is gently advanced through the colon. As in gastroscopy, air is passed through the colonoscope to give a better view of the tissues. This air being released into the colon during the procedure can cause some discomfort for the patient (similar to the feeling of flatulence). The patient may also feel pressure as the colonoscope is advanced through the colon.

During the procedure, the physician is able to take pictures of different views of the colon as well as diagnose and/or treat certain conditions. If bleeding is the issue, as is the case with hemorrhoids, the physician can usually stop the bleeding with epinephrine injections, surgical clippings or cauterizing (heating the surrounding tissue in order to close the wound), each of which can be done endoscopically. As in gastroscopy, a physician can also take samples of tissue masses and polyps to test for cancer and other conditions or completely remove masses.

A colonoscopy usually lasts between 15-30 minutes.

Side Effects/Risks

The side effects associated with a colonoscopy are usually minor and do not require medical attention. Side effects such as mild cramps, nausea and bloating (due to the excess air in the colon) are common, but usually subside within 24 hours. In addition, the patient should drink plenty of fluids after the procedure as the laxatives taken before the procedure can cause dehydration. Serious complications can include bleeding, bowel perforation, infection, fluid imbalance and reactions to the sedatives (ie: difficulty breathing, low blood pressure, low heart rate). With an incidence rate of 5 out of 1000 people, the risks associated with a colonoscopy is relatively low and can depend on the patient’s medical history and the procedures preformed (removal of polyps carries a greater risk) as well as the amount of sedative given.

Latest Research/Developments

New research into different ways of investigating the interior of the human body is occurring frequently and several new techniques have been found that provide a less invasive and more comfortable procedure. Two examples of these new techniques include virtual endoscopy and capsule endoscopy.

In a virtual endoscopy, a three dimensional image of the particular organ/system is created using a CT (computed tomography) scanner or an MRI (Magnetic Resonance Imaging), without the new for the insertion of an endoscope. In most cases, the preparation for this procedure is the same as having a classic endoscopy, however the patient will not require sedation and the procedure is shorter with less complications. In the case of a virtual colonoscopy, the patient will be asked to lie on their back and carbon dioxide gas will be pumped into the rectum through a tube (in the case of a CT scanner) or, in the case of an MRI, contrast material will be administered in the rectum. This improves the visualization of the colon and can give more accurate results. After the scan has taken place with the patient lying on their back, they will be asked to lie on their front and another scan will be done. Ideally, this will give the physician clear computer generated images of the colon, from which to llook for any abnormalities. One negative aspect about this procedure is that the images are computer generated and not always as reliable as actual images. In addition, if an abnormality is found using the virtual endoscopy, a classic endoscopy will have to be preformed to further investigate the cause of the abnormality or to perform surgical procedures.

In capsule endoscopy, a miniature video camera that is shaped like a vitamin pill is given to the patient to swallow with a glass of water. Using a wireless recording device that is placed around the patient’s waist, images of the gastrointestinal track can be recorded without the need for invasive procedures. This procedure is often done when an abnormality is suspected in the small intestines, where a gastroscopy or colonoscopy cannot reach. As capsule endoscopy only provides images and, like a virtual endoscopy, cannot be used to perform surgical procedures, capsule endoscopy is not recommended to replace the classic endoscopy, but rather to serve as an alternative imaging tool to provide images of areas that could otherwise not be seen using the classic endoscopic procedures.

Links

Canadian Association of Gastroenterology – http://www.cag-acg.org/

American Gastroenterology Association – http://www.gastro.org/

References

“Capsule Endoscopy in Gastroenterology, Mayo Clinic in Arizona.” Mayo Clinic. Web. 30 July 2011. <http://www.mayoclinic.org/gi-sct/capsuleendo.html>.

“Colonoscopy: MedlinePlus Medical Encyclopedia.” National Library of Medicine – National Institutes of Health. Web. 20 July 2011. <http://www.nlm.nih.gov/medlineplus/ency/article/003888.htm>.

“EGD – Esophagogastroduodenoscopy: MedlinePlus Medical Encyclopedia.” National Library of Medicine – National Institutes of Health. Web. 20 July 2011. <http://www.nlm.nih.gov/medlineplus/ency/article/003888.htm>.

“Virtual Colonoscopy – National Digestive Diseases Information Clearinghouse.” National Digestive Diseases Information Clearinghouse. Web. 28 July 2011. <http://digestive.niddk.nih.gov/ddiseases/pubs/virtualcolonoscopy/>.

Photo Credits: National Cancer Institute and the Gastroenterology Professional Association

Questions answered in this video include:

1. What is the natural sexual response cycle?          
2. What phases can sexual dysfunction occur in?    
3. What are the types of dysfunction that exist within the desire phase?
4. In a decrease in sexual desire with age normal? 
5. What are the treatments for low sexual desire?  
6. Which phase of the cycle does Erectile Dysfunction belong in? 
7. What is the definition of Erectile Dysfunction?
8. Is it normal for a male to occasionally experience difficulty obtaining an erection?
9. What proportion of the male population deals with Erectile Dysfunction?
10. What are the causes of Erectile Dysfunction?
11. What parts of the population are at high risk to develop Erectile Dysfunction?
12. What are the treatment options for Erectile Dysfunction?
13.  Are there any serious side effects with Viagra?
14. What types of dysfunctions can males experience in the orgasm phase?
15. What is the medical definition for premature ejaculation?
16. Are there any treatments for premature ejaculation?
17. What role does a male’s partner play in the disease process?
18. Are there any reliable online resources with accurate information about these diseases?

Dr. Derek Bochinski graduated from the University of Alberta Faculty of Medicine in 1997 and subsequently completed his Urological Surgery residency training at the University of Western Ontario. He became a fellow of the Royal College of Physicians and Surgeons of Canada in 2002. He completed a combined two year basic science research and clinical fellowship in neurourology and sexual dysfunction at the University of California, San Francisco. He joined the department of Surgery, division of Urology at the University of Alberta in 2004. His current clinical practice interests include sexual dysfunction, Peyronie’s disease and endourology.

Questions answered in this video include:

1. Is hypertension considered a disease or a symptom?
2. At what point is blood pressure considered to be hypertensive?
3. What do the two numbers in a blood pressure reading represent?
4. What is the difference between primary and secondary hypertension?
5. What causes hypertension?
6. Does sex or ethnicity affect a person’s risk of developing hypertension?
7. What are the long-term complications of hypertension? What sorts of treatment options are there for hypertension?
8. How effective are current medications at lowering blood pressure?
9. Do blood pressure medications have any major side-effects?
10. What is the prognosis for a middle-aged adult newly diagnosed with hypertension?

Dr. Peter Hamilton is a respected hypertension specialist from the University of Alberta. In his practice, Dr. Hamilton runs one of the largest hypertension clinics in the province. He is currently involved in several large-scale research projects in the area of hypertensive disease, and has published numerous scientific articles on the topic.

Questions answered in this video include:

1. What is psoriasis?
2. How common is psoriasis?
3. Who can develop psoriasis?
4. Can dry weather trigger psoriasis?
5. What are some other trigger factors for psoriasis flare-ups?
6. Does psoriasis have any other symptoms besides skin rash?
7. What does a psoriatic skin rash look like?
8. What are the most effective treatment options for psoriasis?
9. Do these treatments help with symptoms other than the skin rash?
10. Are all topical treatments steroid-based?

Dr. Jaggi Rao is a board certified dermatologist, licensed in both Canada and the United States. He is also a clinical professor of Dermatology and coordinator of the residency training program at the University of Alberta. After completing his dermatology training, Dr. Rao became the first Canadian physician to be accepted to the prestigious American Academy of Cosmetic Surgery fellowship training program. He has authored a large body of scientific articles and textbook chapters, has presented at countless medical meetings, and has served as a peer reviewer for prominent medical journals, including Dermatologic Surgery.