Dr. Abhishek Yadav, Consultant, Dept of Gastrointestinal Surgery & Liver Transplantation
“Jigar Ka Tukda” is a common aphorism in hindi to address someone who is extremely dear to us, translated to english “Jigar ” is “ Liver”, so it goes without saying how important an organ the Liver is for us. The importance can also be gauged by the fact that a person can not survive without a functioning liver beyond a few hours and unlike other essential organs like the heart, lung , kidney the liver can not be supported by machinery like dialysis machines and artificial heart pumps.
Being as important an organ as it is, many of us are ignorant about the symptoms which tell us that our “Jigar” is not working well. There are hundreds of such signs and tests that doctors can do to look at your liver functions, however below are some that you can pick up yourselves, some of these are subtle and tend to be ignored, and this is the reason why liver specialists usually see patients at an advanced stage of their disease.
Skin and eyes appear yellow (jaundice) – Liver is responsible for the removal of toxic substances from the body, bilirubin is one such toxin excreted by the liver. An unhealthy liver will not excrete bilirubin resulting in its accumulation in the body rendering the yellow colour.
Fatigue and tiredness – Improper functioning of the liver leads to deficiency of essential vitamins and nutrients resulting in easy tiredness and fatiguability.
Itchy skin – Accumulation of toxins in the body is responsible for the itching all over the body and should prompt consulting a liver specialist.
Pain in the abdomen and swelling – The liver is situated in the right upper side of the abdomen, pain and swelling there or all over the abdomen should be consulted with a liver surgeon.
Decrease in appetite and altered taste – Accumulation of toxins and lack of nutrients in liver disease will cause decreased appetite and aversion to food that you usually relish.
Tendency to bruise easily and excess bleeding – The liver is the production house for most substances needed for blood clotting, an unhealthy liver will cause you to bleed easily and excessively. A common presentation could be excessive bleeding for women in their monthly cycles
Swelling of feet and body – Excess water accumulates inside the body in liver diseases thus causing swollen feet and other parts of the body.
Foul breath – The liver excretes ammonia from the body, in the presence of liver disease ammonia is removed through the breath instead of the liver thus making the breath foul smelling.
Black coloured stools – There is a tendency for bleeding inside the intestines in liver disease thus making the stool to be black tarry in colour and foul smelling. This is a feature of serious liver disease and should warrant urgent consultation with a liver specialist.
Dr. Arun Oommen, Consultant Surgeon, Department of Neurosurgery
Brain tumor refers to formation of abnormal cells within the brain. There are two main types of brain tumors: cancerous(malignant) tumors and indolent(benign) tumors. Presentation may include headaches, seizures, problem with vision, vomiting, decreasing sensorium and mental changes. The headache is classically worst in the morning and relieved with vomiting. More specific problems may include difficulty in walking or speaking.
Most brain tumors are not linked with any known risk factors and have no obvious cause. But there are a few factors that can raise the risk of brain tumors. . Even if a person has a risk factor, it is often very hard to know how much it contributed to the tumor.
The best known environmental risk factor for brain tumors is radiation exposure most often from radiation therapy to treat some other condition., Before the risks of radiation were known, children with ringworm of the scalp (a fungal infection) were sometimes treated with low-dose radiation therapy, which increased their risk of brain tumors as they got older. Nowadays most radiation-induced brain tumors are caused by radiation to the head given to treat other cancers esp treatment for leukemia. These brain tumors usually develop around 10 to 15 years after the radiation. Radiation-induced tumors are still fairly rare, but because of the increased risk (as well as the other side effects), radiation therapy to the head is only given after carefully weighing the possible benefits and risks. The possible risk from exposure to imaging tests, such as x-rays or CT scans, is not known for sure. Some studies claim that it may increase risk for tumours like meningiomas and gliomas. These tests use much lower levels of radiation than those used in radiation treatments, so if there is any increase in risk, it is likely to be negligibly small.
Immune system disorders and drug induced
People with impaired immune systems have an increased risk of developing lymphomas(cancers of lymphocytes ) of the brain or spinal cord. A weakened immune system can be congenital (present at birth), or it can be caused by treatments for other cancers, treatment to prevent rejection of transplanted organs, or diseases such as AIDS.
Giving the cancer drug methotrexate into the fluid around the spinal cord (intrathecal methotrexate) for the treatment of leukaemia has been shown to increase the risk of brain tumours. But any increase in brain tumour risk from cancer treatment is small compared to the risk of not having the treatment for the original cancer.
Post menopausal women who are taking hormone replacement therapy (HRT) or oral contraceptives may have a slightly increased risk of developing meningioma but more research is needed to confirm this.
Most people with brain tumors do not have a family history, but in rare cases (5%) brain cancers run in families. In general, patients with familial cancer syndromes tend to have many tumors that first occur when they are young. Some of these familial cancer syndromes and the associated brain tumours include Neurofibromatosis type 1 & type 2 (schwannomas, meningiomas, gliomas, neurofibromas, ependymomas) Tuberous sclerosis(subependymal giant cell astrocytomas) Von Hippel-Lindau disease (hemangioblastomas) Li-Fraumeni syndrome (gliomas), Gorlin syndrome (basal cell nevus syndrome),Turcot syndrome, Cowden syndrome
Environmental factors such as exposure to solvents, pesticides, oil products, rubber, or vinyl chloride (a chemical used to manufacture plastics), petroleum products, and certain other chemicals have been linked with an increased risk of brain tumors..
Exposure to aspartame(a sugar substitute) and infection with certain viruses(Epstein Barr virus, human Cytomegalovirus, polyoma virus) have been suggested as possible risk factors, but research on these continues..
Factors with uncertain, controversial, or unproven effects on brain tumor risk:
Cell phone use
This has been the subject of a great deal of debate in recent years. Cell phones give off radiofrequency (RF) rays, a form of energy on the electromagnetic spectrum between FM radio waves and those used in microwave ovens, radar, and satellite stations. Cell phones do not give off ionizing radiation, the type that can cause cancer by damaging the DNA inside cells. The phones, whose antennae are built-in and therefore are placed close to the head when being used, might somehow raise the risk of brain tumors.
In 2011, International Agency for Research on Cancer (IARC) classified mobile phone radiation as Group 2B – possibly carcinogenic. That means that there “could be some risk” of carcinogenicity, so additional research into the long-term, heavy use of mobile phones needs to be conducted.
Studies to date provide no indication that environmental exposure to RF fields, such as from base stations, increases the risk of cancer or any other disease.
There are some inconclusive studies that Cell phone users had a mild increased risk of malignant gliomas. ,and acoustic neuromas.
Tumors are more likely to occur on the side of the head that the cell handset is used.
One hour of cell phone use per day may increases tumor risk after ten years or more. The same is true of any possible higher risks in children, who are increasingly using cell phones.
Cell phone technology also continues to change, and it’s not clear how this might affect any risk.
All these needs to be proved with further research and studies.
So as of now recommendations to reduce such risks can be by
Using an earpiece such that the hand set is away from the head
Avoid continuous use for more than 15- 20 minutes
More use of texting
Do not use telephone in a car without an external antenna.
Avoid using cell phones in fast moving objects like vehicles, lifts etc
Encourage people using phone continuously like receptionists, call centre workers etc to use land phones
Body size and Exercise
Overweight may have a slightly higher risk of meningioma than in smaller people. But being overweight doesn’t seem to affect glioma risk. Children weighing 4kg or more at birth have a small increased risk of some brain tumour types compared with lighter babies.Taller people might have an increased risk but the evidence on this is still mixed. Studies that look at food and drink in relation to brain tumour risk are not felt to be reliable. This is because brain tumours are relatively rare and measuring diet accurately is very difficult. People who are very physically active might reduce their brain tumour risk but the evidence is mixed.
Diet, Smoking and Alcohol
Some studies of diet and vitamin supplementation seem to indicate that dietary N-nitroso compounds may raise the risk of both childhood and adult brain tumors. Dietary N-nitroso compounds are formed in the body from nitrites or nitrates found in some cured meats, cigarette smoke, and cosmetics. It’s not yet clear whether smoking affects brain tumour risk. But some studies have shown increased risks for some types of brain tumour. Drinking alcohol doesn’t seem to affect risk.
Headache occurring in later onset of life and gradually increasing in intensity. There can be a constant aching pain without any painfree period inbetween. Usually Headache maximum in the morning and the victim wakes up with severe headache
Projectile vomiting mostly on waking up in the morning. Here the vomiting will not be preceded by nausea. Vomiting offers temporary relief to the headache.
New onset seizures with can be focal seizures ( More significant) involving only part of the body or it can be generalized seizures.
Weakness or numbness- progressively increasing and can involve only one limb or one side of the body.
Visual problems especially when it involves the optic Nerve( nerve of vision) or pituitary gland.
Cognitive problems occurring suddenly like memory problems, behavioral changes, language problems , confusions etc
Difficulty in speech when tumour involves the speech area
Gait disturbances, imbalance ,in coordination or weakness of facial muscles
Rapid personality changes
Tumours like Meningiomas, Certain Gliomas, Pituitary adenomas, Nerve sheath tumors, germ cell tumours, haemangioblastomas, cavernomas, and certain Lymphomas are curable.
Survival rates in brain tumors depend on the
- Type of tumor, size, area involved and early detection
- Age and health of the patient,
- Extent of surgical tumor removal.
The primary and most desired course of action is surgical removal (resection) via craniotomy. Minimally invasive techniques is the trend in neurosurgery. Endoscopic surgeries are also being done. With the availability of ultramodern operating microscopes, neuronavigation systems, Cavitron ultra sonic aspirator, endoscopes and other sophisticated instruments along with better understanding of surgical techniques, the safety and success rate for brain tumour surgery has dramatically improved.
Radiotherapy is the most commonly used treatment for brain tumors. Radiosurgery is a treatment method that uses computerized calculations to focus radiation at the site of the tumor while minimizing the radiation dose to the surrounding brain. Types of stereotactic radiosurgery, include Gamma knife, linear accelerator and Cyberknife.
Chemotherapy: is a treatment option for cancer, and can improve survival in 20% brain cancers.
Role of pharmacological therapy is limited except for anti epileptics(controlling fits) and steroids(reduce brain oedema)
Extensive research and studies are going on for better understanding of the behavior of different brain tumours and more and more treatment modalities are being tried to fight this dreaded disease. Immunotherapy/ biological response modifier (BRM) therapy, Oncolytic virus therapy. Targeted therapy of faulty genes or proteins, Gene therapy. Hormonal therapy, photodynamic therapy and Electric field therapy are some of the treatment modalities that may bring hope in the future.
Dr. Roy J. Mukkada, Senior Consultant & Head, Dept. of Gastroenterology
Fatty liver and inflammatory bowel diseases were unheard two decades ago. However, both the diseases are now widely reported in the state, particularly in Kochi. The huge increase in lifestyle related diseases such as fatty liver is contributed by a paradigm shift in the food habits and sedentary lifestyle (westernization, lack of exercises) of people.
Life style related diseases have been witnessing a sharp increase in recent times and are found mainly in teens to middle aged people. The fatty liver disease witnessed 30 per cent increase compared to the previous years.Though such cases have been increasing, majority of the people are still not aware of the risks and don’t undergo evaluation and treatment on time. Fatty liver can progress to cirrhosis and liver cancer, if not diagnosed and treated on time.
Non alcoholic fatty liver disease (NAFLD/NASH) is the commonest cause of cirrhosis in people who don’t consume alcohol. Obesity, Diabetes mellitus (uncontrolled), Dyslipidemia or Hepatitis B and C infections are some of the other cause of fatty liver. Evidences have emerged that patients with Fatty Liver or NAFLD may be at risk for development of metabolic syndrome and insulin resistance. The risk of cardiac illness is higher in patients who have fatty liver and hence regular cardiac evaluation is advisable. Treat the underlying disease properly (diabetes, dyslipidemia or hepatitis) and do regular exercises and weight reduction of at least 10 percent which will help in controlling NASH.
In difficult cases, when there is difficulty in achieving adequate weight loss after diet and physical exercise, bariatric surgery may be considered as a viable option to reduce weight which in turn will improve diabetes and improve fatty liver. Day care procedures like Endoscopic Intra gastric Balloon or Angiographic Embolization may also be done for weight reduction.
There are certain genetic diseases which cause iron and copper overload and deposition in liver which in turn can lead to cirrhosis. There is no need to worry if the ultrasound gives a report of fatty liver, we would need to correlate with other blood tests and also MR Elastography, which can detect the earliest changes of liver cirrhosis in fatty liver.
Another disease, which has increased in recent times, is irritable bowel syndrome. The disease has a direct relationship with stress which people have, among which work-related stress is the commonest. People may present with loose stools or increased frequency of motion after taking food or when they are about to go for a travel or function. It can be treated with medication and occasional counseling. But the importance is differentiating it from other major illnesses like inflammatory bowel disease or colon cancer. So they should get medical advice especially if there are alarm symptoms like weight loss or bleeding from anus, age above 50 and family history of such illness.
Dr. Shawn T. Joseph, Associate Consultant, Head & Neck Surgical Oncology
“It is not just curable with this surgery, but even your quality of life will be unhampered and you will live as long as you would have, if you had not developed this disease”. As I was concluding my counseling to Eliz, the 25 year old emerging architect, who had come to me with a recent diagnosis of thyroid cancer, I saw rays of hope back in her wet eyes. She was recently married and was part of a growing firm of four young and ambitious architects. Correcting her voice which sounded broken during most parts of our discussion, she thanked me and agreed for the surgery. Now, two years later, she is disease free, has progressed in her career and life, with a will much stronger than before. As I reminisce her case and of others treated for thyroid cancer with similar outcomes, I can only thank the consistent effort put in by generations of medical scientists who have worked to bring about excellent outcomes in thyroid cancer treatment, for any disease of thyroid requiring surgery was considered doomed not long before. Present day patients of thyroid cancer and doctors who treat them owe a lot to those doctors who have fought an unrelenting battle against a disease which seemed impossible to even alleviate, if not cure, and faced severe criticisms and ridicule, during the time they practiced.
Thyroid gland removal or thyroidectomy is one of the safest and effective surgeries at present, for diseases of thyroid which require surgery. Even cancers of thyroid can be cured in about 90% of patients by way of surgery and adjuvant therapy. It would be hard to believe that thyroidectomy was one of the most condemned surgeries till the latter part of 19th surgery, due to extremely high procedure related mortality and morbidity rates. Cancers which have spread to distant parts of the body are usually treated with a palliative intent only as most of these are considered incurable. But in case of thyroid cancer, it is possible to treat and control disease which has spread to distant parts of the body with radio iodine therapy, which is a major leap and milestone in the treatment of any cancer. This change from 75% of patients dying due to any form of thyroid surgery even for a non cancer disease to reaching a >90% cure rate with cancer of thyroid with zero procedure related death and extremely low morbidity represents the fight generations of medical scientists have put forward in tackling this problem, once considered impossible to treat.
As the fear of increasing incidence of cancer looms large over the human race, it is probably worth remembering the war human race has fought against thyroid cancer and how they, from a position of no hope, have almost conquered it.
What is Thyroid gland and why it is important
Thyroid, the small butterfly shaped gland situated in front of our neck is essential for most of our bodily functions. But it also represents a marvelous fight human beings have put against the most perilous disease of our times- ‘cancer’.
It may be hard to imagine that this small gland which weighs just about 25 grams has control over almost all major functions of the body by way of its control over metabolism and protein synthesis. This starts right when you are in your mother’s womb, for a deficiency of thyroxin- the hormone it produces can severely hamper intellectual development. Thyroid hormones- thyroxin and calcitonin play an important role, right from normal brain development of a fetus to maintaining the rhythm of heart beats of an adult.
It derives its name from the Greek ‘Thyroideus’, which means ‘shield like’, probably due to its shape. But by way of its function in shielding the body against numerous problems, thyroid gland justifies the meaning of that name. It plays important role in controlling basal metabolic rate of the body, cardiac rhythm, ensuring normal development, maintaining normal sexual function, sleep, thought patterns etc.
Increasing thyroid cancer- is it real or an increase in detection alone?
The world observes September as the ‘Thyroid Cancer Month’.
There is an appreciable increase in the incidence of thyroid cancer in most regions of the world in the past few decades. The number of thyroid cancer patients has shown an increase in India as well, with some states like Kerala showing a threefold increase in number over the past three decades. There is an ongoing debate among physicians whether this is a real increase or an apparent increase in number due to increasing imaging investigations. Though this is not clear, it is generally considered to be an increase in detection of thyroid cancer by way of increase in imaging investigations for management of diseases of thyroid or unrelated to it. However, it is striking that mortality from thyroid cancer has seen a steady decline over the years. It is at present one of those cancers with the highest cure rates.
Treatment of thyroid cancer requires a multi modality approach, with surgery being the main stay. Other treatment modalities like radioactive iodine, hormonal suppression and rarely external beam radiotherapy or chemotherapy may also be required as adjuvant.
History of thyroid surgery
The story behind the therapeutic triumph against thyroid cancer dates back to ancient times and is marked by heroic efforts at surgery of thyroid and collaboration of scientists belonging to different fields.
At present times, the 5 year survival of differentiated thyroid cancer, which forms 90% of all thyroid cancers, is close to 95%. Complications which can arise from thyroid surgery are an injury to the recurrent laryngeal nerve, which is the voice nerve, which is very rare these days in expert hands and mortality from surgery is almost unheard of. And today there are debates concerning ambulatory thyroid surgery and endoscopic thyroid surgery. Contrast this with 1850s, when many major centres around the world had a mortality rate from thyroid surgery, be it benign or malignant, of around 75%, which brought about a ban for thyroid surgery, by the Academy of Medicine in France. It is said that the eight patients among the first twenty thyroid surgeries that Theodore Billroth, a legendary surgeon of 19th century performed had died due to the surgery itself. And in a well known quote John Dieffenbach, a surgeon from Berlin, had stated in 1848 that, “thyroidectomy was one of the most thankless, most perilous undertakings, which if not altogether prohibited, should atleast be restricted”. Thyroid surgery was dismissed as foolhardy performances by most European surgeons of that time.
The scenario of thyroid surgery changed dramatically in the latter half of 19th century, thanks mainly to a Swiss surgeon by name, Emil Theodore Kocher, the first surgeon ever to win a Nobel prize, who worked to promote antiseptic wound treatment and minimizing blood loss in thyroid surgery. This was a time when the advent of Anesthesia and antiseptic techniques had made a huge impact in the surgical outcomes. The mortality from thyroid surgery, as reported by Kocher in his patients, came down to 0.5% by 1900. This was due to the meticulous surgical techniques of Kocher, his understanding of finer anatomy of thyroid and the strict peri operative care given to the patients.
The success with effective thyroid surgery made surgeons realize another problem, that of their patients developing problems associated with thyroid gland deficiency. This led researchers to work on this, leading to isolation of thyroxin, the thyroid hormone, by Edward Calvin Kendall of Mayo Clinic on the Christmas day of 1914. This later led to synthesis of thyroid hormone by the London Chemical Pathology Professor, Sir Charles Harington in the 1920s, slowly solving the problems associated with thyroid hormone deficiency arising out of surgical removal of thyroid gland.
Alongside these surgical advances, was the discovery of X- ray by Roentgen in 1895 and its use to produce tissue damage. Emil Grubbe of Chicago was one of the first physicians to use x rays in the treatment of cancer. With studies and reports from multiple centres across the world, soon radiation therapy became an important part of cancer treatment. It could be used as primary treatment of solid tumors or to treat microscopic disease left after surgery. Many refinements in radiation equipments and delivery have made it more effective over the years. But it had its side effects and limitation of dose and the area where it is given. It was not possible to treat cancer which has spread to distant parts with either surgery or radiation.
Radio iodine and why it represents a major leap in any cancer treatment
Thyroid gland concentrates most of the iodine in the body, iodine being the essential ingredient for thyroid hormone production. The American physician Saul Hertz discovered the use of Radio active iodine for the treatment of thyroid diseases in 1941. His studies in collaboration with the physicist Arthur Roberts of Massachusettes Institute of Technology demonstrated tracer capabilities of radio active iodine and its effects on thyroid gland. This made an important addition to the surgical treatment of thyroid cancer, as it is practically impossible to predict 100% removal of thyroid gland by surgery. There is always the possibility of leaving microscopic thyroid tissue near critical structures like the recurrent laryngeal nerve and parathyroid gland which maintains calcium metabolism of the body, in an attempt to preserve its function. The discovery of radioactive iodine made it possible to target even microscopic remnants of thyroid tissue, left after surgery, without significantly affecting any other organ in the body, as almost 80% of the iodine is absorbed by thyroid tissue alone. Also radio iodine made it possible to treat thyroid cancer which has spread to distant parts of the body. This was a paradigm shift in the treatment of cancer, as cancers which have spread to distant parts of the body are usually considered extremely difficult to treat. Now, from a time when thyroid surgery for even a non cancer was considered impossible, we were reaching a position where we can treat even disseminated thyroid cancer, that too without major morbidity. The role of external beam radiation in thyroid cancer has significantly come down after the emergence of radioactive iodine therapy.
Now we have emerging drugs which can act on molecular level targets involved in the causation of recurrent and advanced thyroid cancer. It may not be long before we can cure differentiated thyroid cancer of any stage with molecular targeted therapy.
Thyroid cancer treatment in many ways reflects the fight human beings have put against the most vicious disease of our times, cancer. From a period when there was a ban on thyroid surgery for even benign tumors, due to the almost certain mortality, we have reached an age where we are curing more than 90% of thyroid cancers, without any significant morbidity. A triumph which is marked in the history of modern medicine as the combined effort of medical scientists belonging to multiple specialties, different generations, and different geography, all united by the passion to make their contribution in the preservation of the ever enigmatic mystery called Life.
|MAIN TYPES||Papillary thyroid cancer|
|Follicular thyroid cancer|
|Medullary thyroid cancer|
|Anaplastic thyroid cancer|
|SYMPTOMS||Firm to hard swelling in front of neck*|
|Unusual firm recent onset swelling on the sides of neck|
|Unusual Voice change|
|Difficulty in swallowing food|
|Difficulty in breathing|
|Kindly note that as most of these symptoms can occur in other conditions as well, consult your family physician first in case of doubt|
|INVESTIGATIONS||Thyroid function tests*|
|Ultra sound scan of neck|
|Fine needle aspiration cytology from the swelling|
|Calcitonin, calcium, Carcino. Embryonic antigen (medullary carcinoma)|
|Genetic tests (rarely|
|* Please note that a normal thyroid function test alone does not mean presence or absence of thyroid cancer|
(Varies from case to case)
|External beam radiation|
|FOLLOW UP||Blood tests like Thyroglobulin, anti thyroglobulin antibody, thyroid function tests|
|Ultra sound scan of neck|
|Calcitonin, CEA (in case of medullary thyroid cancer)|
|More than 90%cases of thyroid cancer can be cured if appropriate treatment taken|
Dr. Roy J. Mukkada, Senior Consultant & Head, Dept. of Gastroenterology
Inflammatory Bowel Diseases consist of Ulcerative Colitis and Crohn’s Disease. In recent years, we have seen a rise in Crohn’s disease throughout Kerala.These patients presents usually with loose motion, bleeding per rectum, weight loss, abdominal pain etc. In children, there may be a problem with weight gain. Most of the time, they will have a stunted growth. When compared with ulcerative colitis, crohn’s disease has more problems and more complications. All these has to be on regular follow up and treatment. IBD needs lifelong treatment. There are new treatment modalities now available which can fairly control the disease. The reason of increase in IBD is probably due to westernization. But there is no clear cut data regarding this.