Category: Fast Facts

Leprosy (Hansen’s disease)

Introduction
Leprosy has a rich history dating to biblical times.

“Leper” is an ancient term used to identify patients with leprosy who were severely stigmatized by the deformity that resulted from Mycobacterium leprae infection.

In the clinical context, the term Hansen’s disease should be used instead of leprosy. Gerhard Henrick Armauer Hansen, a Norwegian physician, discovered the microbe in 1874 just before Koch’s discovery of Mycobacterium tuberculosis.

Epidemiology
In Mexico, in the last 16 years the prevalence of Hansen’s disease has been reduced about 95%, from 16,694 reported cases in 1990 to 820 reported cases in 2006. The World Health Organization (WHO) established the goal of eliminating leprosy as a public health problem by the year 2000, with “elimination” defined as a reduction in prevalence to <1 case per 10,000 population in all endemic countries. The six countries with the highest rates of endemic leprosy in 2001 are: Brazil, India, Madagascar, Mozambique, Myanmar, and Nepal Transmision
This disease is probably spread by the respiratory route, like tuberculosis.

Risk Factors
Close contact
Older persons
Impaired cell mediated immunity

Clinical manifestations
The cardinal manifestations of leprosy are infiltrative skin lesions, hypoesthesia, and peripheral neuropathy
The clinical manifestations of leprosy are closely related to the polarity of the cellular immune response to M. leprae in the patient.
The history of a patient with suspected leprosy should include whether the person has resided in an area with high prevalence and whether the person has been previously diagnosed or treated for leprosy. Certain patients may deny knowledge of a prior diagnosis or may report that skin lesions or neuropathy or both are acute, as they wish to avoid the stigma of a diagnosis of leprosy, even in emigrants to developed countries.

If lepromatous leprosy is left untreated, it can progress to “leonine” facies as seen in the following images.

Diagnosis
This includes physical exam and skin biopsy.

Treatment
Once monthly: Rifampin, Dapzone and Clofazimine for two years and then stop.
Daily: Sulfone and Clofazimine for two years and then stop.

Results of treatment

National Survey for Health and Nutrition in Mexico (2006)

The 2006 National Survey for Health and Nutrition in Mexico (Encuesta Nacional de Salud y Nutrición 2006, a.k.a. ENSANUT) revealed that among mexican adults, 70 percent have obesity or overweight.

There were not states in the Mexican Republic with smaller prevalence to 55 percent.

Campeche, Chihuahua, Durango, México City, Estado de México, Quintana Roo, Sonora, South Baja California, Tabasco and Yucatán have obesity prevalence greater than 75 percent.

This means that one of every three adolescents have overweight or obesity, wich is about 5.7 millions of adolescents.

This data is very important because obesity and overweight are risk factors to cardiovascular disease, diabetes and cancer.

The survey also points that about 47 percent of people with hypertension and 37 percent of people with hypercholesterolemia don’t know that they suffer this diseases.

It also adverts that the prevalence of low height in children younger than 5 years old it is alarming, affecting about 1.2 millions of children. Prevalence of anemia in this age group was 23.7% (1.8 millios of children).

As you can see, Mexico stills in the third world and I found this too disappointing.

Top Ten causes of death in Mexico

Several times, some people have asked me what causes death to mexicans.

On the last mortality statistics (2004) of general population, the main causes of death were [independently of sex]:

  1. Heart disease – 16.4%
  2. Complications of Diabetes Mellitus – 13.1%
  3. Cancer – 12.9%
  4. Traumatic injuries – 7.4%
  5. Liver disease (alcoholic and non-alcoholic) – 6.2%
  6. Stroke – 5.7%
  7. Perinatal complications – 3.5%
  8. COPD – 3.0%
  9. Pneumonia & influenza – 2.6%
  10. Kidney failure – 2.0%

References:

INEGI

Screening Measures for Cancer

Elisa Camahort wrote at Healthy Concerns a Frequently Asked Question: What are the best preventative screeinngs -of cancer- we all should do?
By now, there is evidence for three types of cancer, the recommendations of the US Preventive Services Task Force are the following:

Breast Cancer

  • Screening mammography, with or without clinical breast examination, every 1-2 years for women aged 50 and older.
  • Discusse with women in their 40s.
  • Women should be screened until their predicted life expectancy is less than 10 years.
  • Women with a strong family history should receive counseling for several options, which may include genetic testing for BRCA-1 and BRCA-2 and more intensive screening for breast cancer.
  • Regular clinical breast examinations.

Cervical Cancer

  • Target sexually active women with an intact cervix, starting three years from age of onset of sexual activity or at age 21.
  • Screening is routinely done by cytological examination.
  • Among women with repeatedly negative findings, screening more often than every three years rarely detects important conditions.
  • Screening women with previous negative findings every three years is a reasonable approach.

Colorectal Cancer

  • Target patients over age 50 years: Annual FOBT (Fecal Occult Blood Test) plus flexible sigmoidoscopy every five years OR colonoscopy every 10 years.
  • Patients should be asked about first and second degree relatives who have had colorectal cancer (number of relatives and age of diagnosis).
  • In order to screen high risk patients, ask the following questions starting at age 30 and update every 5 years: Have you ever had colorectal cancer or an adenomatous polyp? Have you had inflammatory bowel disease (ulcerative colitis or Crohn’s disease)? Has a family member had colorectal cancer or an adenomatous polyp? If so, how many, was it a first-degree relative (parent, sibling, or child), and at what age was the cancer or polyp first diagnosed?.
  • Patients at high risk should have screening colonoscopy starting at age 40 years, or 10 years younger than the earliest diagnosis in their family, whichever comes first, and repeated every five years.

Other Types of Cancer

  • There are not evidence to recommend screening.

Regards,

Dr. Jon Mikel Iñarritu

Gallstone Ileus

Gallstone Ileus is an infrequent cause of mechanical bowel obstruction. It is caused by an impaction of a gallstone in the terminal ileum by passing through a billiary-enteric fistula (often from duodenum). It occurs more frequently in women with average age of 70 years.

Clinical picture: Episodic subacute obstruction in an elderly female. Abdominal pain and vomiting which subside as the gallstone becomes disimpacted, and only recurs again as the progressively larger stone lodges in the more distal bowel lumen. Intermittent symptoms may be present for some days prior to evaluation. Hematemesis could occur as an occasional complication that is due to hemorrhage at the site of the biliary enteric fistula.

Physical examination: The patient may be febrile and often appears dehydrated. Common abdominal signs include distension and increased bowel sounds. Jaundice is uncommon, occurring in less than 15% of cases. Many affected patients have serious concomitant medical illnesses, including coronary disease, diabetes mellitus or pulmonary disease.

Diagnosis: The most important diagnostic test is abdominal plain film. The diagnosis of gallstone ileus is made preoperatively in about one-half of cases. The radiographig findings of gallstone ileus, are:

  • Signs of partial or complete intestinal obstruction
  • Air in the biliary tree (pneumobilia)
  • Direct visualization of the stone
  • Change in position of a previously located stone
  • Two adjacent small bowel air-fluid levels in the right upper quadrant

Treatment: First of all, as any kind of bowel obstruction, the objective is to relief intestinal obstruction after adequate fluid repletion. The options are enterolithotomy, cholecystectomy, and fistula division, with or without common bile duct exploration (one-stage procedure), with definitive repair performed at a second operation (two-stage procedure).
The treatment of choice is the enterolithotomy wich consits in localize and extract the gallstone. Often the cholecystectomy is contraindicated by comorbidities and the general state of the patient.

Case presentation: A 72 year old woman with heart faliure, hypertension and diabetes came to the office with a chief complaint of chills, abdominal pain, nausea and vomiting followed by inability to pass flatus 8 hours prior to consult.

On physical examination the patient was febrile and appeared dehydrated. Abdominal exam: distension and increased bowel sounds. No jaundice.

Labs: Hyperglicemia, mild renal failure, hypernatremia and leukocytosis.

Radiographic tests: Abdominal plain film with signs of bowel obstruction and with not apparent cause, negative US. CT scan just with signs of intestinal obstruction, not pneumobilia, not obstructing gallstones.

The patient bacame hemodinamically unstable while performing the US and we decided to open her. On the OR we found the level of obstruction at terminal ileum and we felt a solid mass. We performed an enterolithotomy and the result was this:

Gallstone Ileus

Regards,

Dr. Jon Mikel Iñarritu

Splenic Injury and Hemoperitoneum in Blunt Trauma

The following pictures are from different clinical cases.

In Blunt Trauma the spleen and the liver are injuried in 40 and 20 percent, respectively.

In the ER, you have three four options in the Work-Up of a patient with blunt abdominal trauma

  • Peritoneal Lavage: Now just performed if you haven’t access to ultrasound (lack of money or lack of trained personnel). It’s indicated in specific cases, as in patients with cranial trauma, spinal trauma, for example.

Positive Peritoneal Lavage - 1 Positive Peritoneal Lavage - 2

Look the blood in the syringe and the tube. This is a positive peritoneal lavage due to blunt trauma.
  • Ultrasound (a.k.a. FAST or Focused Abdominal Ultrasound for Trauma): This is one of the most used techniques, and should be performed for those patients hemodynamically unstables who can’t go to the coputed tomography room.

Positive FAST
Look the irregular border. This is a positive FAST for hemoperitoneum due to blunt trauma.
  • Computed Tomography: This technique has a magnific resolution for spleen, liver and vessels. Excellent evaluation for retroperitoneum. It has one inconvenience, hemodinamically unstable patients are not candidates for this analysis.

Spleen Injury and Hemoperitoneum
Black arrow = Hemoperitoneum.
White arrow = Injuried spleen
  • Diagnostic Laparoscopy: Almost never recquired.

Positive Diagnostic Laparoscopy
Look the blood in the abdominal cavity, this is a positive Laparoscopy for hemoperitoneum due to blunt trauma.

The controversy is when the hospital is not capable of performing the standarized protocol in blunt abdominal trauma (economic reasons), we doctors have to adequate to the circumstances and do our best effort.

For example, the first two photographs (peritoneal lavage) were taken at the Mexican Red Cross where money is the big problem. The rest, were taken at the ABC Medical Center, a nice private hospital. This are the contrasts of healthcare system and medicine practice in developing countries.

Regards,

Dr. Jon Mikel Iñarritu

Worst case of hemorrhoidal prolapse ever & PPH

BEWARE! Gory image

A 45 year old male with history of chronic reducible hemorrhoidal disease came to the emergency department with excruciating pain, rectal bleeding and an anal non-redicible mass after a bowel movement.

On examination, we found this:
hemorrhoidal prolapse

In this case, the only way to reduce the prolapse is a procedure for prolapsing hemorrhoids (PPH) which is an innovative approach to the management of enlarged, prolapsing hemorrhoids. Rather than rely on excision of the complexes, the primary goal is to reduce the hemorrhoidal tissue and anoderm to the correct anatomical location within the anal canal. It is important to keep this goal in mind, because the misinterpretation of anodermal migration externally as external hemorrhoids leads to unnecessary excision of sensate skin during PPH. In fact, with a correctly performed procedure, the relocated anoderm will shrink over time.

For this, we need an hemorroidal circular stapler kit which includes: clear plastic anoscope, half-slit anoscope, suture threader, and the 33 mm stapler.

Here is an animation video of how the procedure works, and how does the anal canal looks like before and after the procedure.

Regards,

Jon Mikel Iñarritu, M.D.

More information of hemorrhoidal disease in this site is here:
Thrombosed Hemorrhoid

Intussusception

Intussusception is the invagination of a part of the intestine into itself, in other words is the prolapse of one part of the intestine into the lumen of an immediately adjoining part. It is the most common abdominal emergency in early childhood.

Epidemiology: Most episodes of intussusception occur in otherwise healthy and well-nourished children. Approximately 60% of children are younger than one year old, and 80 percent are younger than two. Is the most common cause of intestinal obstruction in children between 3 months and 6 years old. It appears to have a slight male predominance with a male:female ratio of approximately 3:2.

Etiology: The vast majority of cases is unknow. Another causes are Meckel’s diverticulum, polips, intestinal tumors, Henoch-Schönlein purpura, strange bodies, etc.
The most common form of this disease is the ileo-colic and ileo-ileo-colic invaginations. It could be associated with the rotavirus vaccine.

Clinical picture: Acute onset of intermittent, severe, crampy, progressive abdominal pain, accompanied by inconsolable crying and drawing up of the legs toward the abdomen. This painfull episodes occurs at 15 – 20 minute intervals and then become more frequent and severe. Vomiting may follow episodes of abdominal pain.

This episodes can be followed by vomiting and the passage of “currant jelly” stool (a mixture of blood and mucous). A sausage-shaped abdominal mass may be felt in the right side of abdomen. The prevalence of blood in the stool is as high as 70% if occult blood is included.

Diagnosis: It is based on index of suspicion, frequently the diagnosis is stablished with contrast studies (wich could be also therapeutic).

The abdominal plain film (see below) may be helpful because they may show frank intestinal obstruction or massively distended loops of bowel with absence of colonic gas.

Intussusception. Plain film and barium enema

The ultrasound can be useful also, with a sensitivity and specificity approach 100%. The classic finding is a “bull’s eye” or “coiled spring” lesion (see below) representing layers of the intestine within the intestine.

Intussusception. Ultrasound

Treatment: Nonoperative reduction using barium or air contrast techniques is successful in approximately in 75 – 90% (in the first 24 hours) of patients with ileo-colic intussusception.
Surgery is indicated when nonoperative reduction is incomplete or when a persistent filling defect, indicating a mass lesion is noted. Broad-spectrum intravenous antibiotics should be given before surgery. Manual reduction at operation is attempted in most cases, but resection with primary anastomosis needs to be performed if manual reduction is not possible or if a lead point is seen.

Regards,
Jon Mikel Iñarritu, M.D.

Purpura fulminans as severe complication of meningococcal infection

Purpura fulminans

It is a severe condition due to meningococcal sepsis, it occurs in 15 to 25% of those patients with meningococcemia.

The clinical picture is as follows: acute onset of cutaneous hemorrhage and necrosis secondary to vascular thrombosis and disseminated intravascular coagulation. Often there is pain followed by petechiae. Ecchymoses develop and evolve into painful indurated, well-demarcated purple papules with erythematous borders (as you can see in the image this lesions are coalescent). Then this lesions progress to necrosis with formation of bullae and vesicles. Gangrenous necrosis can follow with extension into the subcutaneous tissue and occasionally involves muscle and bone.

purpura fulminans

To prevent this complication of meningococcemia you have to be prompt and agressive with IV antibiotics and support of vascular perfusion. The use of Xigris (drotrecogin alfa activated) have shown promising results once the process has instaled. Often this patients require surgical debridement, skin grafting or limb amputation.

Regards,

Jon Mikel Iñarritu, M.D.

Six Symptoms You Don’t Want To Ignore

Yesterday at Health-Hack.com they made a list of six of the most evident symptoms of some serious illness, via WebMD:

From WebMD:

1. If you have unexplained weight loss and/or loss of appetite, you may have a serious underlying medical illness.

2. Slurred speech, paralysis, weakness, tingling, burning pains, numbness, and confusion are signs of a stroke, and you should get to an appropriate emergency center immediately. Early treatment may prevent permanent damage to the brain or even save your life.

3. Black, tarry stools may indicate a hemorrhage from an ulcer of the stomach or the intestine. It is important to stop the bleeding and to rule out cancer as a cause.

4. A headache accompanied by a stiff neck and fever is an indicator of a serious infection called meningitis.

5. A sudden, agonizing headache, more severe than any you have felt before, could mean you are bleeding in the brain. Go to an emergency room immediately.

6. For women: Vaginal bleeding after menopause is a waning sign of possible cancer.

6. For men: A lump in your testicle with or without a small lump in the groin could be serious. Testicular cancer is more commonly found in testicles that did not naturally descend from the abdomen to the scrotum.

Via Lifehacker.com