How to check for Colon Cancer?

How to check for Colon Cancer?

Colon means large bowel in Greek. The Colon Cancer is one of the most common types of cancers in western world. It is the second in USA. If you catch colon cancer early enough , it could be curable.

Hence doctors want to catch the tumor before it goes beyond the walls and before it spreads all over the body. The tumor tends to bleed. Relatively rare you can see frank blood in your feces when you go in a bathroom.

However if the bleeding is small, you may catch it by using special card for invisible blood. This is named Fecal Occult Blood Test. other name is a Guaiac Card.
Not always blood in your stool means cancer. There are much more conditions that might bleed. Hemorrhoids, for example, anal fissure and so on.

Doctors recommend to undergo colon cancer screening for everybody 50 years or older.
Screening for colon cancer besides Fecal Occult blood test include Colonoscopy or sigmoidoscopy and barium enema. Colonoscopy and sigmoidoscopy are the procedures where doctors look inside of your guts with flexible fiberoptic tubes. Barium enema is procedure where roentgenologist checks the picture of special contrast stuff distribution in the guts using x-ray technology.

To prepare for procedures you will need to have your guts cleaned before procedure. The cleansing happens after using special laxatives and clear liquids. You should do it thoroughly according to protocols. It is not uncommon that a doctor cancel the procedure because your guts where not clean enough to look through.


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Do you need carbon monoxide detector?

Do you need carbon monoxide detector?

You probably saw those Carbon Monoxide detectors at a hardware store. Why would you need one of them?
Carbon monoxide is a dangerous gas. it binds to hemoglobin (the protein that delivers oxygen in you blood). Since it binds to the same place on th molecule where oxygen should go, then the oxygen deliver to your organs from your lungs is going to zero. Basically your brain, organs and tissue choke up.

What are the situations when you can get carbon monoxide poisoning?
Practically, it is any situation where a carbonated fuel is not completely burned out. The gas is going into a closed space. And now you are sitting in this space too.

For example, when you use your gas oven to heat a room (it is not designed for anything other than cooking food). Another case is when you use some gas-powered equipment in a garage - generators, chain saw, lawn mower etc.)
The same goes for grills and portable stoves. Also some faulty fireplaces, furnaces, heaters may produce carbon monoxide. Especially it is true if chimneys are blocked by some soot.
And of cause the car is a typical carbon monoxide producer especially if is run in a closed unventilated space for a long time.


Hence , yeah carbon monoxide defector is a useful gadget at your house.

The carbon monoxide poisoning is dangerous also because the symptoms are developing gradually and not are so obvious in the beginning until it is too late.

Cherry-red lips is a classical sign of the poisoning. Other signs would include headaches, nausea, weakness, dizziness, difficulties with breathing. If you had this , tell your doctor.

First help is actually to get to a fresh air immediately.

Recent studies suggest that carbon monoxide poisoning has long-term consequences and may increase risk of heart attack.

Sometimes, on a cold evening whole family whole family goes to sleep and never wake up in the morning. This is when a carbon monoxide detector could save the life.





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What are Metastases?

What are Metastases?

Metastases are what makes cancer so difficult to treat.
When a tumor spreads into neighbor organs it is named invasion. Then when small clumps of tumor cells travel to another site of body, and give rise to new tumors, that are named metastases. Originally it is a Greek word.

Surgeon can cut out primary tumor relatively easy (unless it invades into an important organ or lies close to big blood vessels or nerves). However dealing with hundreds of small tumors all over the body is a daunting task.

This is why it is important to catch a cancer in the early stages, before wide spreading.


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Pain in the Butt. How to deal with Hemorrhoids?

Pain in the Butt. How to deal with Hemorrhoids?









This is very sensitive area of your body. Too private. Nobody likes when something is wrong over there. However it happens.





Hemorrhoids occur practically in everyone. Though hemorrhoids cause problems in 1 out of 25 people. Mostly those are people between 45 and 65 years of age.




You find a blood on toilet tissue. Bright red blood. Ok, now what? You do not know why you bleed. It could be rectal cancer by the way. It could be hemorrhoids.



So? What are the hemorrhoids?
They look like cushions. They contain blood vessels, some muscle and elastic fibers. People often call them piles.



Not everything over there is a hemorrhoid. There could be other problems. Fissure, abscess, fistula, pruritus (itching), condylomata (sort of hanging skin caused by viral infection), viral and bacterial skin infections can happen in that, so sensitive area.



It is worth to talk to your doctor.



How would a scenario of hemorrhoids look?



A 46-year-old female presents with complaints on rectal discomfort, occasional bright red blood on toilet tissue and prolapsing tissue in of anal area. This is probably internal hemorrhoid.



Another scenario brings a patient who complains on severe rectal pain and prolapsed tissue.
The severe pain happens in external hemorrhoids. The pain follows thrombosis (thrombosis is the blood clot in your blood vessels).



There are four degrees of internal hemorrhoids.

It may be interesting for you to know because first, second and sometime third degree can be treated by banding only. Fourth degree and sometime third degree requires surgery.



Do not forget non-hemorrhoid causes of symptoms.
To check with your doctor is worthwhile because there could be other problems, including cancer or anal fissure. (By the way for anal fissure medical treatment alone may heal it in 90% of cases).



How are hemorrhoids treated?



Well first you need to understand how do hemorrhoids happen. Several reasons lead to hemorrhoids:



Constipation and extra straining


Chronic Diarrhea and loose stools


Long sitting or standing


Weight lifting


Obesity


Pregnancy and childbirth


Inherited tendency to hemorrhoids.





So, avoid all this and you are free.



Obviously this list of reasons is too wide.



The list of measures is wide too.



Increase the fiber in your diet.



Eat more cereals, fruits, vegetables, grains, etc



Psyllium and methylcellulose are supplemental types of fiber.



Exercise, avoid long standing or sitting, don't strain, keep the anal area clean.



Increase liquids in your diet.



Use stool softeners, stool-bulking agents (not a tasty ones, but what can you do).



Treat diarrhea with anti-motility drugs and fiber.



Not every of these methods are proved scientifically. Nonetheless they are included in the standard recommendations for hemorrhoids treatment.



To treat itching or discomfort you may use suppositories, ointments, creams, and gels. You may find that all in your local pharmacy.



These products contain protectant and anesthetics (pain relievers). Local anesthetics numb the area and decrease burning and itching.



Remember that local anesthetics may cause allergy.



Analgesics (menthol, camphor) relieve pain and itching as well



Vasoconstrictors reduce swelling in the perianal area. Though they may have side effects. Better discuss with your doctor.



Protectants (kaolin, cocoa butter, lanolin, mineral oil, starch, zinc oxide or calamine, glycerin, etc) create a physical barrier to prevent contact of stool and the skin. This reduces irritation, itching, and burning.



Similarly, some agents - astringents - dry the skin. That helps to relieve burning, itching, and pain as well.

To kill or at least suppress bacteria and other organisms use antiseptics. Boric acid, phenol, resorcinol and many others can be used. Again better to discuss with your doctor or at least pharmacist. Many of these drugs are sold over-the-counter.



Corticosteroids. Corticosteroids decrease inflammation and relieve itching, but may cause skin damage. They should be used for few days only.



Sitz bath may also help in relieving the symptoms.






When those methods fail your doctor may perform one of the following:



Sclerotherapy (causes scarring of the hemorrhoid).



Rubber band ligation. The rubber band cut off blood supply and hemorrhoid heals with scarring.



Side effects of any of the treatment may be infection of fat and other tissues surrounding the anal canal, especially if patient has diabetes cancer, AIDS.



Another option - electrotherapy and infrared photocoagulation. Works the same way, cause scarring of the tissue.


Cryotherapy uses cold to cause inflammation and scarring. Practically the same, though more time consuming.




Let say your medical treatment fails. What do you do then?
Well, you go to surgeon and treat it surgically.



Operations are done in less than 10% of patients. Though it depends.



Surgical procedures include


Dilation. It is when surgeon stretches your anal sphincter.



Ligation. Often a Doppler probe helps to measures blood flow and finds the individual artery.
The doctor ties off the artery.



Sphincterotomy. It is when sphincter is partially cut. Whole idea is to reduce the pressure.



Hemorrhoidectomy. Hemorrhoidectomy makes sense for patients with third- or fourth-degree hemorrhoids. The hemorrhoids are cut out.



Stapled hemorrhoidectomy. Stapler cuts off the ring of expanded hemorrhoidal tissue.



There are different considerations why to do this and not that type of treatment. And vice versa.



There are complications (pain, difficulty urinating, bleeding several days after surgery, scarring, infection, stool incontinence). Complications happen relatively rare, but they are still there.


Better talk to you surgeon.



I hope you be OK.


You were not alone.


It looks like Napoleon Bonaparte, Carter, Hemingway, Tennyson, Lewis Carroll also were suffering from hemorrhoids.












Humankind suffered hemorrhoids have plagued since ancient time.
This article describes internal and external hemorrhoids.


keywords:
piles, hemorrhoidectomy, inflammatory bowel disease, hemorrhoidal problems, anorectal
problems, ulcerative colitis, Crohn disease, enlarged hemorrhoids, straining, constipation, anorectal varices, prolapsed internal hemorrhoids, rectal prolapse, perianal pain, pruritus ani, thrombosed hemorrhoid, internal hemorrhoid, external hemorrhoid






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Dumb Lamp.

Dumb Lamp.   by Aleksandr Kavokin MD/PhD

Ha...

Here is a funny story an ENT resident told me sometime ago.
It happened in the1st City Hospital in Moscow, Russia. It is actually a very good hospital in
terms of the staff experience. Though the buildings are 100 years old.
Doesn't matter.

So, the resident is on-call. It's midnight. Ambulance rolls in.
A man: U-U-U, M-M-M.
Something metal is sticking out of his mouth.

OK. It turns the guy was at home. Probably drinking.

Those stories about Russians and vodka are partially true.

Partially.

For example, I don't drink at all, even beer. Just don't drink.
Though, Russians are different. We all are.

I knew some guys who drunk 3 bottles of vodka a day for week straight. Those stories about
American colleges, where a student brags that seven people drunk a box of beer and vomited half
night, are nothing.

Kids.

Russia is the Land of Extreme.

Russians drink in company usually. It is considered not healthy to drink alone. Should be three.

Americans have their parties. Russians have their parties.

It's cold in Russia, you know. People are genetically healthier. So they can trash their bodies. To
equalize.

Then they talk about soul, self-respect, and world-wide problems. About Africa, for example. Or
about importance of Daosizm for international culture. The place of a human in Universe is also
a favorite topic. Long night talk.

Again, not everybody drinks vodka in Russia.
I don't. Never did. My father doesn't. My grandfathers and relatives don't'.

I heard Putin also doesn't drink much. Some wine during American visits. He prefers judo.

That man in the hospital maybe was sober.

Anyway. In a company he bet he can put a light bulb into his mouth.
This is why I say: Maybe.

So, the bulb gets in. It's it.

Stuck.

It turns: it is easy to put a bulb into mouth, but it is difficult to get it out.
The muscles locked in. Trismus. (Trismus is condition when your masseter muscle spasms. It
happens in people with tetanus. Masseter muscle is the muscle that clench your jaws).

I actually do not know how to explain it exactly.

It seems there are some anatomical and physiological reasons.

The muscles that open your mouth are relatively weak. In contrast the masseter is very strong
(Of course. You needed to crunch nuts and bones in the ancient past). So, the opening muscles
are probably tired first. But masseter is not tired. You can not get the bulb out unless you crunch
it.

At least, this is how I would explain it.

Anyway, the resident scratches the back of his head, then injects novocaine and a muscle
relaxant into the muscle and gets the bulb out.
He returns the bulb to the patient.
Man lives the room.

This where the fun starts. Five minutes later another man gets into ER. The same big metal screw
is sticking out of his mouth.

It turns, the previous patient called a taxi and told the driver a whole story. The driver decided to
try it himself. Just out of curiosity.

It reminded me: surgeon at med school told us how he was trying to get out a wide glass bottle
cork out of a patient's rectum.
The guy was experimenting with homosexuality or something like this. It was tough job. Glass is
too slippery for any forceps.

You think this side of the Ocean is better?

Think again.

Recently I read a book: Cases in Emergency Medicine. The book is printed in New York.

" A 24-year old man was brought to the emergency department. .. He had placed a firecracker in
his anus and lit it. The explosion brought him to attention of bystanders..."

In the same book: "We have removed from rectal ampullae a variety of foreign bodies including
pop bottles, razor blades and electric vibrators..."

People do dumb things anywhere in the world.

Children are very susceptible to foreign bodies problems at certain age - around one to four years
old.
Around one - one and half years, they crawl and bring everything they see into their mouth. Then
they choke.

This is why now toy manufacturers are required to make toys with the big parts, not fitting into
mouth.

Later children get different objects into mouth, nose, ears just out of curiosity. Does it fit?

It fits.

I remember. When I was a child, I visited a local children ambulatory clinic in Kazakhstan. Just
a routine well-being check up annually. Everybody did.

They had a stand. I always was fascinated by that display. That was a glass box. LOR-doctors
extracted different objects form the little patients. (LOR = larynx, otis, rhinos = throat, ear,
nose).

There was a hundred of the objects: coins, small balls, peas, seeds, buttons, etc. Everything that
can get in.

So, watch you children.

Also, if you see a light bulb, don't taste it.
Never, ever, ever try to do it at home. Don't stretch your dumb luck.

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Medical question #2. Ovarian cysts.

by Aleksandr Kavokin MD, PhD

Medical question #2. Ovarian cysts

Ms. L wrote me:

Hello Dr. Kavokin,

I was reading some of your literature and found it to be quite informative. I have a question that perhaps you may be able to answer: If a woman's ovarian cyst ruptures, (especially multiple cysts from PCOS) can these ruptured cysts become an infection?
...

Hi, MS. L
Short answer: anything can become infected. Though I do no think ruptured ovarian cyst becomes infected very often, did not hear about that. I will look more literature and probably place the answer on my website.

Sincerely,
Alex
…
OK. I looked the literature.
I didn't do very extensive literature search. Should admit.
Anyway, some available books mention that ovarian cyst may become infected. However the infection is not described as the main complication in ovarian cyst rupture.
Also, I don't remember that anybody told me otherwise. Maybe there is some specialized article that says: the condition happens in one point three percent of cases with Standard Deviation of half percent. I don't know exact percentage. Need to look more. PubMed service did not give many abstracts on PCOS + infection.

Anyway.
So how would it look alike?

A young woman comes to ER. She is premenopausal. She complains on mild (or maybe severe) pain in her belly. ER Doctor takes history. The woman also mentions changes in her menstrual interval. Let's say regular is 28 days. Last one was delayed.

Physician puts gloves, puts jelly on gloves. Then he puts his two fingers into the female vagina.
The other hand is on belly. Then he starts to palpate.

It is named pelvic exam. Modest name. Though in Russia it is named vaginal exam, which it is.

Is it a common type of exam? Depends. They usually send you to CT (computer tomography) scan if there is severe abdominal pain. Charge 1000. Boom.
Done.

Exclude the price. Exclude delay in reading (somebody should look and interpret what is going on). Exclude radiation. CT scan gives better picture than just poking your belly.
CT scan helps to diagnose abdominal pain of uncertain origin. You can really image what is going on. Though, there are cases when physical exam gives more clues. Physical exam must be performed always. Pelvic exam is somewhat a special one.
I remember how I performed a pelvic exam in medical school. It is actually difficult even just to insert two fingers into vagina first time.
Female Gynecologist asks me: "So, what do you feel?"
Patient goes the same, encourages me:
"What do you feel, what do you feel, do you feel it?"
I guess she felt a sort of museum artifact.
Heck, I did not feel anything.

Well. Actually I felt something - aside from uterus - something round. I would say 5 cm in diameter (would it be less I probably would not feel it at all) and semi-solid on touch. Also I saw that the patient grimaces. It is tender when I push hard.

It's it. How to say that it was tuboovarian abscess (that it was) for sure, I don’t know.
You really need experience to perform this type of exam. Experienced gynecologist can tell almost precisely what is going on.

Let's discuss that woman in ER. She will have tenderness on one side. Physician should be able to feel a mobile cystic mass.
(Cyst or rather cystis is Latin for bubble. Palpate is Latin for touch. It means you touch something and feel what it is).
What if the pain is severe? It often means that the cyst ruptured.
My impression is that modern ER orders CT scan right away. If you are not very sure what is going on, you will go from less expensive methods to more expensive and end up with CT anyway. Ruptured cyst causes significant pain. Here CT is indicated.

Alternatively they may order Ultrasound Exam. Transvaginal ultrasound uses the probe inserted into vagina. Ultrasound is cheaper than CT. Ultrasound visualizes cysts clearly. Though, ultrasound gives less information for excluding other pathology. Ultrasound is also safe from the radiation point of view.

In PCOS ultrasound shows increased number of small cysts in both ovaries. Usually more than five confirms the diagnosis.

Culdocentesis may give some useful information too. The name came from cul-de-sac. It's French I guess. Cul-de-sac is one of the pouches in the pelvis. Centesis means: stick a needle and draw. These days it is considered an outdated method. But if you do not have other machines, it is very useful.

If the content is blood, the ruptured cyst was probably Corpus luteum cyst. If the content is purulent the ruptured thing was probably a tubo-ovarian abscess or other pelvic inflammatory disease (PID).
Other abnormal masses can rupture as well. Teratoma gives oily fluid, endometrioma gives "chocolate" old blood.

What is a follicle?

Female body is created for reproduction and childbearing. Oocyte is the start for a new human being in the ovaries. Several layers of specialized membranes surround an oocyte.

The membranes protect the oocyte, help in feeding and nurturing of this small cell.
One of layers has a beautiful name Zona pellucida. Pellucida means shiny in Latin.

When the oocyte matures, a small bubble (follicle) filled with special fluid is formed around.
In mid-cycle the follicle bursts and the oocyte goes first into peritoneal cavity, next into ovarian tubes (fallopian tubes). The tubes lead into uterus. Tubes, by the way, have special small hair-like things inside - fimbria. They beat in one direction. They propel the oocyte into uterus.

I remember I read somewhere that there are 11000 follicles. When a girl is born, there is no more multiplication of oocytes. After the birth the follicles sit dormant. When the female goes into her reproductive age, the follicles start to grow and mature (one by one).

Only 400 of them mature.

Yeah, it should be like this. Calculate. Average cycle is 28 days. So there are around 12 cycles a year. Women start to menstruate at 13-15 years old. The menopause is around 45-55 years. Total is 30-40 years

Multiply everything together. It should be around 400.

By the way, an interesting thought.

All those discussion about abortion and Stem Cell research.
Somewhere in nineteen century the baby was considered the baby when it was born. The church even struggled to admit anything like existence of cells etc. Rare baby actually survived beyond first year.
Heck, the hypothesis that human been consists of small cells was actually admitted widely not so long ago. Maybe hundred years ago. Then, all that research happened. People learned how the fetus is created and how it grows. Now the public idea is that fertilized oocyte is already the baby.

Have you seen any oocyte under microscope? Even a human hair near an oocyte looks like a skyscraper near a real human.

Now, if the public perception had shifted this way in several decades, shouldn't we punish all women for that they recklessly loose 400 potential babies during lifetime. Isn't it a crime?

Then, maybe we should punish every man for losing millions of sperms - also potential babies.
Where did this idea come from that fertilized oocyte is the baby and non-fertilized oocyte is not?
Shouldn't we move the boundary a little bit earlier?
Need to think about that.

Anyway.

Ovarian follicle (follicle means small bubble in Latin) usually mature, rupture and release the oocyte that was in this follicle. Sometime the rupture delays. Then ovulation delayes. (Ovulation is rupture and release of the oocyte. Oocyte is the cell that eventually becomes the fetus after sperm gives the genetic material).

Normal cycle is divided into follicular phase (when the follicle grows) and luteal phase.
Luteum means yellow in Latin.

When the follicle ruptures (by the way rupture means burst or tearing), the oocyte goes out.

The cavity that left behind (remember it was small bubble) is filled with blood and special cells, producing hormones. These special cells grow in quantity and fill that cavity. These cells produce hormones that help the fertilized oocyte to attach and to grow in the uterus. Because they grow in quantity, they create a yellowish body in the ovary. It is literally yellowish. The name is Corpus Luteum (corpus=body, luteum = yellow).

This is normal cycle.

As we said, the follicle sometime doesn’t rupture (there is a bunch of reasons). A physician should sort out several different conditions. This is an abnormal cycle.
If follicle does not rupture it becomes the follicular cyst. Cyst also means bubble in Latin. There are actually plenty of different kinds of bubbles in medical Latin. Big ones and small ones. Normal and abnormal.

OK, the cyst did not rupture. Then what happens?

Well. If cyst doesn't rupture, it usually resolves. That fluid inside the cyst is reabsorbed and the cyst collapses.

However, if the cyst ruptures, it causes acute pain. The pain comes from irritation of peritoneum (lining of peritoneal cavity) with blood and cyst content.

Why it is not painful when a regular follicle ruptures and releases the oocyte? Probably, a regular follicle is too small. In addition it doesn't cause much bleeding.

In contrast the cyst is a really big bubble (sometime 5-10 cm in diameter). If it ruptures, it instantaneously release bunch of special fluid. Plus, there is significant bleeding because there are a lot of blood vessels around to feed.

Significant is of course relative.

For example, take 5-10-20 ml of blood from a patient vein in a hospital daily. He complains about the pain from the needle mostly.

But if you get the same 10 ml of blood into peritoneum... Wow.
You will cry. There are plenty of nerve endings. Peritoneum is too touchy-feely. Tender.

Besides, the cyst has high concentration of prostaglandins. Prostaglandins, in their turn, are mediators of inflammation. They should cause significant pain directly and indirectly.

From the other hand bleeding could be really significant. Then it becomes really dangerous.

A physician also should not miss an ectopic pregnancy. Doctor will order a pregnancy test for that. If an ectopic pregnancy starts to bleed, this is really really worrisome. It seems like your blood did not left your body. However the blood is in the abdominal cavity. It left the blood vessels. It is internal bleeding. You die quickly.

Polycystic ovarian syndrome is a little bit different animal actually. Here is some genetic predisposition.

Classically: an overweight young female presents with oligomenorrhea or amenorrhea, anovulation, acne, hirsutism, and or infertility.

What is what? Poly = many. Many, many, many men.
So PCOS means bunch of those bubbles in the ovaries. The follicles did not rupture on time, as they should. Oligo means a little. Meno is derived from menses. Rrhea means flow in Latin

So olygomenorrhea = flowing a little bit (less than it should).
A- is a prefix that means "No". So, amenorrhea = no flow at all.
Hirsutism. I don't remember where it came from, but means hairy or hairiness. Actually excessive hairiness.

Causes of PCOD or PCOS (disease or syndrome) are obesity, genetic predisposition and some other causes of Luteinizing hormone (LH) excess.

There is a self-amplifying cycle:

LH stimulates theca lutein cells. Theca means sort of capsule. Doesn't really matter, just an anatomical term.
Those cells are special. They produce androstendione and testosterone. Androstendione and testosterone are actually male hormones. You know, bodybuilders use these hormones to get muscle bulk. You probably heard about those hormones. Sport doping uses testosterone.
So, athletes build their muscles and trash their liver.

Rumors say that a famous Hollywood actor used the hormones. Later he got liver transplant.
Though he always denied the use.

Anyway, female body converts androstendione into estrone (a weak estrogen). Fat cells do this. Estrone is a female hormone already.

Basically any body produces androgens (andros = man) and estrogens (female hormones). Just the proportion of those hormones makes us male or female.

The cycle happens in normal person as well.

The estrone stimulates pituitary secretion of LH.
Pituitary is a small gland in you brain. Pea Size.
It's small, but it sooooo powerful.

Pituitary has another name - hypophysis. Hypo means down, phys means growth, so this gland is growing from below the rest of the brain. Pituitary gets bunch of connections from hypothalamus.
Hypothalamus means “below thalamus”.
These two areas of brain regulate almost all the hormone production in organism.

Higher levels in brain hierarchy regulate them.

Hypophysis gets a command. Then it produces some intermediate messengers and hormones.
The hormones go into blood and control whole body.

Hormones are like orders, like messages to the rest of the body.

Brain may give quick orders: Signals go through the nerves. It is like a phone order or cablegram.

Brain also regulates organism through the hormones. This is like a mail order.
Sort of if the brain sends letters by regular mail. The hypophysis is the Post Office in this case.

PCOS kicks in when a woman is obese. There are more fat cells to convert
androstendione to estrone. Estrone has such effect that it stimulates pituitary secretion of LH.
LH in its turn goes back to those theca lutein cells we discussed and turns them on again, to produce more androstendione, which is again converted into estrone.

Self-amplifying cycle

In addition, that increased level of testosterone causes the hirsutism (she becomes hairy like a male) and acne in female.
In a normal person this cycle is probably designed to support the development of fetus.
Estrogen helps placenta to grow. Placenta supports fetal growth.

However, in a person with PCOD the cycle is going out of normal control. In this case LH causes growth of the cysts in the ovaries.

Why?

Because the corpus luteum cyst is partially made by overgrowth of those theca lutein cells. LH stimulates theca lutein cells.

Also, women with PCOS have intolerance to glucose (sugar) and resistance to insulin.
It means there is a lot of insulin (hormone that helps to utilize glucose mainly).

However excessive insulin does not work. Either receptors to insulin do not work or something else, but the glucose is not utilized. Hence, energy inside the cells drops. Hence, a big pile of other problems mounts. As if it is Diabetes Mellitus. Diabetes is a different topic of discussion. For us, it is worthwhile to mention that people with diabetes are very much prone to any infection.

PCOS causes acanthosis nigricans also. Acantocytes are special skin cells.
Nigricans means black in Latin. That thing looks like thickened pigmented skin. When you touch it, it feels like velvet. Usually it happens in axilla, neck, below breast, in inner thigh and vulva. So, mostly all those places where skin folds.

The treatment for PCOS includes different medications: oral contraceptives, progesterone,
glucocorticoids, ketoconazole, spironolactone, cyproterone, flutamide, cimetidine, finasteride, ovarian wedge resection, laparascopic electoracutery, mechanical hair removal, etc.

All methods break the cycle of overproduction. The medications are either hormones themself or hormone-like substances that occupy receptor site and prevent regular hormone to work.

The medications act on different levels. Normal hormones have very complicated regulation. There are loops and feedbacks in the pathways.

To suppress a hormone production or action, you give similar hormone or another hormone or non-hormone at all, that goes to the feedback loop and breaks it and so on. It's really long separate discussion.

Basically, you either decrease hormone production or shift ratio toward female hormones.

Another way, the best probably, is weight loss. No fat cells - no conversion of andrgoens etc… You can make conclusions yourself.
It's the first line of treatment.

For a simple follicular ovarian cyst (not PCOS) doctor rules out ectopic pregnancy. Then he may send patient home and repeat pelvic exam in 6-8 weeks. Especially, if the cyst was small, less than five cm in diameter.

For larger cysts, doctor would order pelvic ultrasound.

Most follicular cyst will resolve on their own in six to eight weeks. Though, a physician may give oral contraceptives. Again, this suppresses stimulation of cyst by hormones from the hypophysis. The hormones are named gonadotropins.

If the cyst is still there after 6-8 weeks, a suspicion arises that the cyst maybe malignant. Then doctor orders other studies. CT scan. Physician may perform surgical procedures also. He looks what is this cyst really.

Corpus luteum cyst is usually not treated. However, oral contraceptives may be used.

Rupture of any kind of those cysts leads to another story. Acute pain, bleeding into peritoneum.
Sometime bleeding is very severe and is true emergency. You need also to distinguish other process in the abdomen. For example, appendicitis looks similar. You can treat mild case of non-complicated cyst rupture with just observation. Appendicitis almost always requires surgery.

There are many other problems arise. Surgeon scratches his head: what's going on? Is this this or is this that? Here is the CT scan gives big advantage.

Now, going back to the question of Ms. L.

If the cyst was infected, I don't' see a reason why a ruptured cyst wouldn't become infected.
Cyst content is very nutrient-rich. Remember? All those cells and their products are dedicated to feeding the oocyte (future baby). Should be very tasty for any bacteria.

Rupture may cause significant bleeding as well. This blood is also different from the blood in your vessels.

This blood is sitting in the pelvis, not moving, quickly clotting. Clotting prevents entry of white blood cells. "No flow" prevents entry of antibodies. Absence of flow prevents entry of other protective chemicals (complement etc).

So, it is very nutrient-rich media for bacteria growth.

They can go wild. Why not?
If a female had another pelvic infection before, that infection can flare up. In a normal person peritoneal cavity should be sterile. However, any gynecological or gastrointestinal infection may supply bacteria. Now, mix these bacteria with the content of the leaking cyst. It just destined to become infected.

Actually Ms. L later answered her own question in another e-mail. She had cysts multiple times and they became infected several times.

So, to answer the question:
Will the ruptured cyst become infected? Not necessarily. Rather not. Can it become infected?
Yes.

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Appendicitis. Treatment. part 7.

Appendectomy is performed urgently usually. Thomeo is Latin for dissect or cut. Lapar - is abdomen (belly) in medical Latin. Laparotomy is opening of belly. Appendectomy is cutting of appendix. Laparoscopy is looking (by scope) into belly. Antibiotics almost always are given prior to surgery as soon as appendicitis is suspected. Few patients have mild "confined appendicitis" localized to a small area. These patients may improve during several days of observation when treated with antibiotics alone. Doctors may or may not removed the appendix later. Chances are you are not one of this patients. If a person has not seen doctor for many days while appendicitis ruptured (yeah, sometime happens; there are some tough guys), an abscess may form, and the perforation may close. Initially it can be treated with antibiotics; however, that will require drainage later. A drain is guided under ultrasound or CT scan and appendix is removed after the abscess resolves. In modern days surgeons offer laparoscopic appendectomy. They insert laparoscope (it is like a small telescope with a video camera) and remove appendix with special instruments through small puncture wounds. If you had this type of surgery, you will probably have four 1-cm size scars and you will go home in one or two days. But if your case is complicated or there is just no laparoscopy in the hospital, they will do classical appendectomy. Surgeon cuts 10-cm incision in the area of the appendix. Appendix is removed form the right lower abdomen or where it is. Area is checked for other problems. In the case of abscess the purulent stuff will be drained with rubber tubes through the skin. With that kind of surgery you will probably stay for four to seven days. Antibiotics will help to resolve the abscess. This is why you sign the consent: "laparoscopic appendectomy, possible conversion to an open appendectomy". The most common complication of appendectomy is wound infection. If it is severe, the surgeon will postpone incision closure for several days. Ok, now you have those four small scars or one big scar, you go home and visit that party that you missed.


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Appendicitis. Part 6.

At this point diagnosis is usually clear. In cases if it is not, there is Laparoscopy. Laparoscopy is a surgical procedure. Small fiberoptic tube with a camera is inserted into the abdomen through a small puncture in abdominal wall. Yet there is no test that will diagnose appendicitis with 100% certainty. The position of the appendix may vary. If it is longer than normal, appendix may go deep down into the pelvis. It also may move behind the colon (called a retro-caecal appendix). From one hand it is better because retro-caecal appendix has less chances to burst into peritoneal cavity, from the other it is difficult to diagnose and it is difficult to approach surgically. Inflammation of other organs, for example, female pelvic organs, may resemble inflammation of the appendix. Pregnant women may have appendix pushed up in abdomen by the enlarged uterus. Athletic young adults may tolerate more pain and may have not so obvious symptoms of appendicitis. Old patients may have vague symptoms as well. Other inflammatory problems may mimic appendicitis. Surgeons often observe patients with suspected appendicitis for a period of time to see if the problem will resolve or suggest appendicitis more strongly versus another condition. Conditions that mimic appendicitis are: 1) Meckel's diverticulitis. 2) Pelvic inflammatory disease -infection of tube and ovary. It is treated with antibiotics alone 3) Fluids from the right upper abdomen may drip into the lower abdomen and cause inflammation resembling appendicitis. Then, for example, patient has gallbladder disease or liver abscess, but all symptoms suggest acute appendicitis. 4) Diverticulitis that occur on the right side. 5) Inflammation of right kidney. 6) Crohn's disease or ulcerative colitis 7) Yersinia enterocolitica infection - the bacteria that comes form certain food - like unpasteurized milk. - may cause appendicitis 8) passing kidney stone 9) ectopic pregnancy 10) ovarian cyst rupture. And so on. There are some other conditions.


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Appendicitis. Part 5.

cause this count to be abnormally high. It is not specific for appendicitis, but it confirms other findings. Next, doctors check Urinalysis - microscopic examination of the urine. That detects red blood cells, white blood cells and bacteria in the urine. When there is inflammation or stones in the kidneys or bladder, the urinalysis is abnormal. A normal urinalysis is more characteristic to appendicitis. Next they try to image what is going on in your belly. An abdominal x-ray may detect the fecalith as the cause of appendicitis (5%). Free air due to perforation can might be seen on the plain film. A barium enema may be used. It is an x-ray test where liquid contrast is used from the anus to fill the colon. Sometimes it show an impression on the colon in the area of inflamed appendix. Barium enema also can exclude other intestinal problems that mimic appendicitis. Ultrasound shows an enlarged appendix or an abscess. Ultrasound is painless, but the appendix can be seen in only half of patients. Ultrasound also is helpful in excluding the problems with ovaries, fallopian tubes and uterus. Ultrasound machine usually looks like a small thumb on wheels that they bring into your room. Technician puts gelly on and drives the probe over you belly. Often they go straight to CT Scan (computer tomography). Especially if the patient is not pregnant. CT scan gives relatively high irradiation of your body by x-rays. However benefits of prompt diagnose of appendicitis outweigh the risk of radiation. CT scan gives slicing images of your body. What do they look for? As any inflamation causes edema, the wall of the appendix will be thickened. This is actually a defensive mechanism - by edema the organism try to wall of, to seal off the area of infection and inflamation. But it is useful for us because we can surely say there is an inflammation. The same goes for ultrasound. CT scan is expensive - around 1000 dollars in an American hospital, though 40 dollars in Russia. If the CT scan is taken during the night, CT image may be send to Australia Russia or India. An American radiologist is paid around 40 dollars to read just an X-ray film. I guess he gets more for reading the CT scan. It is only 5 dollars in India. This is why even such clinics as Harvard and Yale adopt this model of work - they send the CT scans to the cheap labor abroad. Especially during the night. Half an hour later the fax from Australia arrives. "Inflammatory pericecal mass in the right iliac fossa consistent with the diagnosis of severe acute appendicitis." Any doctor can read an x-ray film or CT scan. Radiologists are doctors who specialize in the reading of the films. They may find what was missed by others.



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Appendicitis. Part 4.

Diagnostic problem with appendicitis is that some other conditions may mimic it. Abdominal cavity is packed with different organs. Other sources could cause pain in right lower quadrant. Females may have ovarian torsion or tuboovarian abscess or extrauterine pregnancy (this is why doctors persistently ask: when was your last menstrual period? Are you taking contraceptive hormones? Did you have vaginal bleeding?), etc. They also check your chorionic hormone, trying to find if you are pregnant.

Scrupulous doctor asks your permission to perform rectal exam. Many people refuses to do it. I can understand that. Who would like that somebody sticks fingers into his ass. I wouldn't. But the rectal exam gives a lot of information. Rectum - is the part of gut that is closest to the back orifice. Back orifice is named anus in Latin or anal canal. Surgeons say that there are only two contra-indications for avoiding rectal exam: 1. patient does not have anus 2. Surgeon does not have fingers. Rectal exam in appendicitis is usually unremarkable. Maybe you can cause pain by palpating the side wall of the rectum that is close to the appendix. But the rectal exam allows to distinguish other disorders. During the rectal exam you may palpate hemorrhoids, uterus, nodules in prostate or enlarged prostate, you may feel fluid in lower part of peritoneal cavity, etc. You may see blood on the finger telling you about internal bleeding. You may check the stool for small amount of blood (named fecal occult blood test - FOBT - or Guaiac test by the name of the dye that turns blue in the presence of blood. At last rectal exam may help in dis-impaction of rectum. That is when hard stool causes bowel obstruction. Usually a rectal exam is more or less normal. But every surgeon will tell you a war story about how once in while, once in five years he found something significant on rectal exam, something that every other doctor missed. Just by putting the finger into the butt. I saw how a surgeon put a finger into an old, demented women and pulled out a pessarium. It was an apple-size pink plastic membrane , that should go into vagina, but somebody (at home?) put it (by mistake?) into the rectum of that woman. You really need to push hard to get such big object into the anus. The poor lady suffered bowel obstruction for a week and would probably die if it stayed long enough.



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Appendicitis. Part 3.

With modern technology it becomes much easier to distinguish appendicitis and other causes of pain in right lower quadrant. Yet there is no 100% proof diagnostics. Sometime doctors treat with antibiotics alone, when they are not sure. Though, modern CT-scan shows appendicitis almost close to 100%. What would happen if you miss the appendicitis and appendix bursts? You will get one of the most dreaded surgical complication - peritonitis. Again, "-itis" equals inflammation. Peritoneum means the peritoneal cavity. It is difficult to describe the shape of the peritoneal cavity . That shape is very complex. Simple explanation: peritoneal cavity is like a closed bag. It is completely closed in males Female have small holes in the peritoneum. Oocytes (future babies) go from ovaries first to peritoneal cavity. The holes in the peritoneum allow oocyte to go into Fallopian tubes. Fallopian tubes lead into the uterus (womb in English or hyster in Latin or uterus in Greek). Organs that are covered by peritoneal cavity linings are named intra-peritoneal. There are also melo-peritoneal, extra-peritoneal or retro-peritoneal organs that covered partially or not covered at all. It looks like the main function of peritoneum (peritoneal cavity) is to give some lubrication to your guts. Though there are other functions as well. Now, take a plastic bag, pour a little bit of water or oil into it and seal. Put one hand on one side of the bag, another hand - on another side of the bag and rub against each other. You can see your hands slide easily. This is the idea of peritoneum - you bowels slide easily against each other even when they are stretched by food and when they are pushing the digested food down. When a bowel is punctured (perforated), the content of the bowel will go into the peritoneal cavity. Colon (lower, bigger bowl) has the fecal material. Fecal material consists of bacteria on 2/3 (yeah, there are so many of them). Now, that small puncture in one part of the gut will cause spillage of the bacteria all around that closed bag of peritoneum. Guts on inside have several mechanisms protecting from bacteria. Peritoneal cavity doesn't' have such a protection. Small puncture in one part of gut will cause all of you guts be inflamed on outside non-protected side (for the gut it is outside, but for the peritoneal cavity it is the inside). This is the peritonitis (diffuse). This what the surgeons are afraid of. Look at you. You belly is like half of you body. So it is like half of you body is severely inflamed. Eventually it may lead to sepsis, a condition in which bacteria enter the blood and infect other parts of the body. This is life-threatening complication. Sometime inflammation stays local and seals off forming an abscess. Abscess is the walled off accumulation of pus. Pus is the mixture of dead and alive bacteria, dead white blood cells (leukocytes; leukos = white, cyte = cell) that fought the infection and honorably died, and dead tissue, that was digested partially by bacteria and partially by the stuff from leukocytes. Inflamed peritoneum (the lining of the peritoneal cavity is also named peritoneum) easily adhere to each other and may seal of the infection - there will be local peritonitis. Any adherence may cause problems in the future - guts do not slide easily anymore and food or stool sticks. Blockage of the intestine may occur in acute appendicitis as well. This is partially responsible for the nausea and vomiting. Sometimes, when antibiotics are used, appendicitis goes away without surgical treatment. It happens in elderly patients. The patients may come to the hospital with a lump or a mass in the right lower abdomen looking like tumor.


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Appendicitis. Part 2.

Classically appendicitis starts as a pain that began in the periumbilical region (around navel - you belly pot). Then pain moves to the right lower quadrant of the abdomen. Nausea and vomiting often present after the onset of the pain. Classically, patient has low grade fever (this means around 37-38 C or 101-102 F), positive psoas sign (you stretch your leg and this movement increases your pain), positive Rovsing sign (Doctor pokes in your left lower quadrant of the abdomen, and you fill the pain in you right lower quadrant), Leukocytosis. Leukocytes are the white blood cells - WBC. Usually there are around 4000-9000 white cells per micro liter of you blood. When you have inflammation in you body the count goes up. Your pain during appendicitis classically localizes in Mc Burney's point. That is one third between your umbilicus and anterior superior iliac spine (this is the bony point that is sticking most prominently from your pelvis - you can palpate it yourself on the side of your belly). For confirmation a doctor also may try to elicit obturator sign - he will ask you to bend you knee and bring your heel to your groin - this manoeuver increases the pain during appendicitis. Similar test is the raising of the leg while you lie on the stretcher. That movement also increases your pain.

Appendicitis is the inflammation of appendix supposedly due to narrowing of this lumen. That narrowing may be caused by hyperplasia of appendix (means too big growth, overgrowth of the tissue) . That variant happens in children mostly. Another variant - is fecalith (small stony fecal material) that impacts into the appendix lumen. That is seen in young adults mostly. Appendix itself is a small part of gut . It is pencil-size sticking out gut. Gut is a continuos tube. Mouth is entry. Anus is exit. Appendix sticks out from the wall and ends blindly. It has only one entrance. Appendix is attached to the Caecum (part of gut - literally means blind colon in Latin). Appendix of ruminating animals (animals that chew grass, like cow) is very long and big. Appendix in humans is reduced to the pencil-size. However it doesn't disappear. There is a theory that appendix plays role in immune response. The walls of appendix are actually filled with lymphatic tissue containing lymphocytes (those are subtype of White Blood Cells). Lymphatics is responsible for immunity. The removal of appendix doesn't really change immunity significantly. Nonetheless, it is not something redundant. Unless it is inflamed there is no good reason to remove it . Now, acute appendicitis is the acute inflammation of appendix. Suffix "-itis" means inflammation in Latin. Appendicitis is also the most common cause of acute abdomen. Acute abdomen in surgery is a condition in abdomen that requires urgent actions, usually surgical. To diagnose appendicitis you need to have right lower quadrant pain. The pain should be present together with either appropriate history (all those classical signs and lack of appetite) or Leukocytosis (increase in white blood cells in the blood). Patients often ask questions: Can I avoid surgery? Can you treat me with antibiotics alone? You told me that it is possible to treat the appendicitis with antibiotics alone. Please, I do not want surgery, my mother (father, brother, fiancee) said that I can avoid surgery. The answer is: you can try to avoid it probably, but the odds of death are much higher if you treat appendicitis without surgery. Untreated appendicitis may lead to perforation in less than a day. Sun rises. Sun sets. Appendix bursts. So, the prompt surgical intervention is the main solution. On occasion, the surgeon may even find a normal-appearing appendix and no other problem explaining the symptoms. He may remove the appendix anyway because it is better to remove a normal-appearing appendix than to miss mild case of appendicitis. To cool down the infection before surgery doctors use antibiotics. Antibiotics may convert acute appendicitis into more chronic type. However the removal of the appendix is the choice.


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Appendicitis. Part 1.

Appendicitis. Aleksandr Kavokin, MD, PhD





It's 10 pm. Severe pain in your belly. You are in ER. Previous day you had a nice party with your friends. Then pain started around your umbilicus (navel). You thought first: aha, probably you ate something bad, it will go away. But it doesn't. You have vomited once and lost appetite. Pain did not improve but worsened. After a day of suffering you decided to visit the hospital. Long taxi trip. Pain is shooting every time the car bumps into a pot. Nurses ask you bunch of questions and place in an available room. There is a confused 90 something years old women in the neighbor room. She mumbles something incomprehensibly. The woman has come from a nursing home. She suffers Alzheimer disease and yells every night for the past 7 years. She has history of multiple medical problems. They brought her in the ER after she developed fever. Nurses draw your blood. You pain is getting gradually worse. Change your position, pull your legs. Pain doesn't go away. When the ... doctor comes? At last ER physician sees you. He writes H+P and ER orders. A stretcher is rolled in. They take you to a radiology department and put into a big machine looking like a gate. Everybody leaves you and the machine drives you into the big metal doughnut. They bring you back into the ER. Surgical intern comes. He did not rest since 5 AM. He asks bunch of the same questions again and pokes your belly. A tired resident comes. He pokes your belly again. You still wait, become bored, complain on delay, call your relatives. It's already 2 AM. At last the resident discuss your symptoms with attending over the phone. He tells you that you have appendicitis and CT scan confirmed it. History and physicals are written. Admission orders are written. Pre-op orders are written. Antibiotics are prescribed. IV fluid is running 80 ml an hour. You sign consent for operation. Transporting guys take you upstairs - depending on severity of your symptoms - straight to or to the floor. Attending will operate you first thing in the morning


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