Abdominal Tuberculosis - Myths, Misconceptions & Facts

Tuberculosis is still common in the developing world; so common that it must be considered in the differential diagnosis of a majority of the medical, surgical and gynaecological presentations.
Abdominal tuberculosis too is quite common. While abdominal tuberculosis is one of the commonest forms of extra-pulmonary tuberculosis, it is ill understood and is being neglected all too often by clinicians and researchers. Surprisingly, even some text books on infectious diseases make no mention of abdominal tuberculosis. Clinical Features It is not generally realised that abdominal tuberculosis denotes the involvement of the gastrointestinal tract, peritoneum and/or abdominal lymph nodes. In a study a series of 90 cases of abdominal tuberculosis, more patients with peritoneal tuberculosis presented with acute abdomen than those with gastrointestinal lesions. Some authors describe abdominal rigidity and tenderness to be the most frequent signs-being present in as many as 2/3rd of the cases. However, others have found them in only 5% of their cases. The difference could perhaps be explained by the fact that the former series included more cases of peritoneal tuberculosis while the latter had mainly included cases with gastrointestinal lesions. It is also incorrect to say that obstruction and perforation are rare in abdominal tuberculosis.
Abdominal tuberculosis should be considered as a possibility in any patient who presents with a lump, ascites, intestinal obstruction or peritonitis.
As many as l/3rd of the patients with abdominal tuberculosis may present with an acute abdomen. Rolled up omentum, doughy abdomen, alternating constipation and diarrhoea are more commonly described in text books but are less frequently seen in clinical practice. The presence of associated pulmonary tuberculosis and/or peripheral tuberculous lymphadenitis is not so common as believed but should be looked for. The average age of Indian patients (26 years) is less than that in the whites (45 years). Does it mean that the Indian disease is different from that seen in the West? Investigations It is wrongly advocated that non specific features like malaise, raised ESR and positive Mantoux test should be taken as diagnostic of abdominal tuberculosis in a difficult to diagnose abdominal problem in an Asian patient. Radiological studies too have a high false negative rate (ileal strictures are more likely to be missed) and may fail to differentiate between tuberculosis and carcinoma. Besides, adhesions may be construed as intestinal lesions. Blind percutaneous needle biopsy of the peritoneum, laparoscopic biopsy and peritoneal biopsy with a small grid iron incision in the right iliac fossa under local anaesthesia have been advocated but are hazardous to carry out except in patients with ascites. To sum up, while diagnosis of abdominal tuberculosis should always be kept in mind, a definite diagnosis needs careful and painstaking investigation. Therapeutic trial with anti-tuberculosis chemotherapy, though recommended is not really justified. Although systemic symptoms like fever, anorexia and weight loss may subside within 4 to 6 weeks of anti-tuberculosis chemotherapy, bowel symptoms take much longer to respond. Also, anti-tuberculosis chemotherapy, given for 4 to 6 weeks for purposes of trial, can alter the histological picture so much that subsequent differentiation from Crohn,s disease becomes difficult.
Pathology and Microbiology The pathology of abdominal tuberculosis is well understood—epithelioid cell granulomas, with Langhan,s giant cells, with or without central caseation necrosis. The histological findings of tuberculosis may be present only in the lymph nodes and not in intestinal lesions. Also, previous anti-tuberculosis chemotherapy may alter the histopathological picture. A monograph on inflammatory bowel disease, surprisingly, says that only bacteriological studies.can differentiate gastrointestinal tuberculosis from Crohn,s disease.
The relationship, if any, between abdominal tuberculosis and Crohn,s “disease (regional enteritis) remains a myth: many cases of so called regional enteritis could only be a manifestation of abdominal tuberculosis because mycobacteria like organisms have been isolated from patients with Crohn,s disease. Haddad et al go to the extent of saying that cases being presently diagnosed as regional enteritis are, in fact, abdominal tuberculosis and, in future, regional enteritis may be described as a variant of abdominal tuberculosis. However, there is sufficient evidence in support of a possible separate entity of regional enteritis.
A large number of cases of inflammatory intestinal disease remain unclassified. Microbiological confirmation of tuberculous etiology is difficult, except in tuberculous peritonitis where processing of one litre of ascitic fluid may yield upto 80% positive results. The mycobacterial strains causing abdominal tuberculosis, at least in India, are of the human type.”
Etiopathogenesis The etiopathogenesis of abdominal tuberculosis-either through ingestion of bacilli, hematogenous spread from an active pulmonary focus or reactivation of a latent abdominal focus-does not explain why the gastro-intestinal tract is involved in some patients but in others the disease remains confined to peritoneum and/or lymph nodes; why do some patients develop ulcero-constrictive lesions, while others have hyperplastic masses and why do some patients with tuberculous peritonitis have frank ascites but others largely develop adhesions? The answers to these questions may come from immunological studies of patients with abdominal tuberculosis.
Surgical Treatment Surgical intervention may become necessary in abdominal tuberculosis for two reasons-diagnostic and therapeutic. Diagnostic laparatomy becomes necessary for histopathological/microbiological diagnosis, more often in patients with peritoneal and/or lymph node tuberculosis. Therapeutic surgery is indicated for complications like intestinal obstruction (acute, acute-on-chronic, chronic), perforation and peritonitis. A textbook of surgery mentions that surgical therapy for hyperplastic lesions is rarely indicated and another (of tropical medicine) makes no mention of surgical treatment at all, but that is not true. Strictureplasty may be performed in patients with multiple ileal strictures to preserve intestinal length, in selected cases. For hypertrophic ileocaecal lesions, the surgical procedure of choice is not a right hemicolectomy but a limited (segmental) resection, including only 5 cms of ascending colon, with ileoascending colostomy.

Anti-tuberculosis Chemotherapy The regimen, doses and duration of anti-tuberculosis chemotherapy for abdominal tuberculosis are becoming fairly standardized, but the role of steroids in preventing adhesion formation remains controversial. Cooke has recommended 12-18 months treatment but Dutt : et al found short course (9 months) regimens to be equally effective. Recently, Balasubramanian et al have shown in a controlled trial that a 6 month regimen is as effective as the conventional regimes in the treatment of abdominal tuberculosis. This can be accounted for by the progress made in the recent past in a clearer understanding of the role of multiple drugs, rhythm of administration, duration of treatment and the mode of action of anti-tuberculosis drugs on tubercle bacilli, wherever they are in the body. The site of the disease in abdomen, however, appears to be important in respect of the clinical response to chemotherapy. While peritoneal and nodal lesions respond well, the healing process in intestinal lesions may lead to increased fibrosis going on to intestinal obstruction. An increased occurrence of perforation has been reported in patients with intestinal tuberculosis who were on anti-tuberculosis treatment. However, Anand et al have shown that surgery was required in only 3 out of 39 patients with intestinal strictures treated with chemotherapy.
The first country to eliminate tuberculosis will be the one which regards the disease as a serious problem, right to the end. We in India need to keep this message always in mind as tuberculosis is one of our “National” disease.

Pharyngitis

Acute Pharangitis
It may be an accompanying feature of many local and systemic diseases e.g. Acute attack of common cold or feature of other infections like measles, chicken pox or influenza. May also develop after trauma or after instrumentation.
The chief symptom is sore throat, associated with fever or other constitutional symptoms. Examination reveals diffuse congestion of the pharyngeal wall, uvula and adjacent faucial tissues. Oedema of the lining mucosa and uvula and enlargement of the glands of the neck may be present.
Treatment consists of bed rest, analgesics and antibiotics preferably erythromycin.

Membranous Pharyngitis
Various diseases local or systemic are associated with membrane formation in the pharynx.
Faucial diphtheria: The condition is caused by Corynebacterium diptheriae. The membrane is greyish white and extends to the uvula and soft palate. It cannot be easily removed and on removal leaves a raw bleeding surface. There occurs marked toxaemia associated with a fast pulse rate, disproportionate to the rise in temperature.
Treatment: Diptheria antitoxin along with erythromycin/penicillin.
Vincent’s Angina:

This condition is characterised by an ulcerative lesion on the tonsils, usually on one side. The lesions are covered by slough, which may extend to the adjacent pharyngeal tissues and gums. Low grade fever and malaise are accompanying features. There occurs characteristically fishy odour.
Treatment is by administering penicillin or erythromycin in addition to analgesics and mouth washes.
Agranulocytosis:

It occurs as a result of sensitivity to drugs like sulphonamide, chloramphenicol, cytotoxic drugs. The symptoms are sore throat, ulcerations in the buccopharyngeal mucosa and false membrane formation. Diagnosis is confirmed by the blood picture which shows marked reduction in neutrophils.
Treatment is withdrawal of the drugs.
Leukemia:

Acute lymphocytic leukemia may sometimes present as oropharyngeal ulcerations with membrane formation. Diagnosis is by blood picture.
Infectious Mononucleosis:

It is viral disease which may sometimes be associated with oral lesions. The uvula may be swollen and there may occur inflammatory lesions in other part of buccopharyngeal mucosa. The blood picture shows leucocytosis and relative increase in lymphocytosis. The Paul-Bunnel test is positive.
Moniliasis (Thrush)

It is a fungal infection of the mouth due to candida albicans. The lesions appear as white or greyish whit patches on the oropharyngeal mucosa surrounded by areas of slight redness.
Treatment consists of local application of nystatin in glycerine.

Chronic Pharyngitis:

Chronic inflammation of the pharynx may be non-specific or specific.
Chronic non-specific Pharyngitis: Various aetiological factors in the nose or oral cavity may produce secondary effects in the pharynx. The most constant symptom is discomfort in the throat with a foreign body sensation. Spasms of cough and tendency to clear throat are common. Tiredness of voice and difficulty in swallowing may occur. Diffuse congestion of the pharyngeal wall may be seen and prominent vessels are seen through the inflamed mucosa.
Treatment: It is difficult to reverse the chronic changes once they have set in. However, symptoms can be alleviated to a great extent. Cough suppressants like codeine phosphate linctus and local application of various soothing paints like Mandl’s paint is of help. Alcohol, smoking, irritants and spicy foods should be avoided.

Benefit of improving Foot Muscle Strength

When we think of strengthening exercises, we often assume this refers only to the development of the compound muscles in the body. This is not always an accurate assessment. You can strengthen other components of the body.
For example, you can employ a variety of exercises for the express purpose of enhancing the strength of the muscles in the feet. And this would certainly be a wise move.
The feet have the unenviable task of supporting your body weight. By increasing the strength levels in the muscles in the feet, you will be able to move without discomfort or limitations. How is this so? The answer can be found in a description in the physiology of the feet.

Description of Muscles in Foot
The foot is primarily comprised of muscles, tendons, blood vessels, and bones. In terms of the muscles, there are 20 specific muscles.
These muscles include
• The anterior tibial
• The posterior tibial
• The peroneal tibial
• The flexors
• The etensors
These muscle all tie together to perform the basic function of the feet. In short, the muscles not only support the ability for the toes to move, the stabilization of the toes and ankle to the ground, the ability to move the foot upwards, arch support and movement of the foot but essentially allow the foot to do what it is intended to do when you wish to use your feet!
And, of course, if you do not work to strengthen the muscles, you will not get the most benefit out of your feet.

Benefit of Feet Exercises
It would be difficult to list all the benefits since there are so many but probably the most obvious benefit would be a reduction in the fatigue of the muscles when you use them. In other words, if you need to stand all day or walk a great deal, you can do so without becoming too tired or sore.
Cramps and foot pain will dissipate as the strength of the foot is enhanced and increased. You could even gain greater range of motion with the foot which will also reduce injuries.

Acute Suppurative Otitis Media

Acute supperative otitis media is a pyogenic bacterial infection of the middle ear. It is a common disorder occurring at all ages and particularly in children.

Aetiology:

The predisposing factors include the following:

i. Nasopharyngeal or nasal packs

ii. Adenoids

iii. High deviated nasal septum.

iv. Nasal polyp

v. Rhinitis and sinusitis

vi. Tumours of the nose and nasopharynx.

vii. Anatomical factor: Short, straight and wide Eustachian tube in young children.

viii. Carelessness on the part of the mother in keeping the baby in a flat position while feeding, thus allowing milk to regurgitate into the nasopharynx and to the middle ear cavity through Eustachian tube.

Eustachian tube is the commonest route through which the infection travels from the nose and nasopharynx to the middle ear. The attack usually follows a common cold or influenza. The viral infection damages the mucosal barrier and bacteria invade as secondary organisms. The commonest organisms include betahemolytic and non-hemolytic streptococcus, Hemophilus influenza, Pneumococcus and Staphylococcus aureus.

The other path by which infection may reach the middle ear is a traumatic perforation in the tympanic membrane.

Pathology and Clinical Presentation:

Stage of tympanic congestion: Hyperiaemia of the mucoperiosteum of the middle ear. Patient complains of pain and fullness in the ear. The tympanic membrane looks congested. No significant hearing loss at this stage.

Stage of exudation: In this stage exudates collects in the tympanic cavity due to constant inflammatory process. The patient complains of marked pain in the ear with deafness. The tympanic membrane shows bulging and looks more congested. Constitutional symptoms like fever and malaise occur.

Stage of suppuration: The pent up inflammatory exudates causes pressure necrosis and perforation of the tympanic membrane. The perforation is central. Intensity of pain diminishes but hearing loss persists. The mucosa of the middle ear cavity if seen through the perforation is much congested and thickened. The discharge is serosanguinous at the onset and mucopurulent later on.

Stage of convalescence or recovery: The disease subsiding and the recovery process begins.

Stage of coalescent mastoiditis: Continued infection and absence of proper therapy leads to inflammatory changes in mastoid cells. The pain which had diminished following stage of suppuration intensifies with increasing deafness and profuse discharge continues to drain from the ear. Fever and bodyache recur.

Treatment:

ASOM has been described as a self-limiting disease provided the patient does not develop a complication.

Despite these advocates, the overwhelming consensus remains that antibiotics are the initial therapy of choice for AOM for 3 very valid reasons. First, after the institution of antibiotic therapy, a marked decline in the suppurative complications of ASOM is noted. Second, practitioners cannot predict with certainty which patients will develop complications. Third, studies have demonstrated that the use of antibiotics improves patient outcomes in both the early and late phases of ASOM.

Most common antibiotics that can be used in this condition are:

Amoxicillin/ Augmentin: Adult 250 – 500 mg PO q8hr; Pediatric: 90 mg/kg/d q8 - 12hr.

Clarithromycin: Adult: 250 – 500 mg PO q12hr; Pediatric: 15 mg/kg/d q12hr

Azithromycin: Adult: 500 mg on day1 then 250 mg/d for 2 – 5 days; Pediatric: 10 mg/d on day 1 then 5 mg/d on day 2 -5 days.

Ceftriaxone: Adult: 1-2 g/d IM for 3 days; Pediatrics: 50 mg/kg/d IM for 3 days.

In Ayurveda Lakshmi Vilas Rasa, Sanjivini vati work well in this condition.

Surgical:

Tympanocentesis and myringotomy are the procedures used to treat ASOM

Developmental defects, Medicines and Folic acid!

Bulk of practice in paediatric surgery deals with correction of developmental deformities that may arise in the baby, and this is one aspect of surgery where the age old adage “Prevention is better than cure “ holds true beyond doubt.

The cause of developmental defects is unclear. Less than 20% are related to genetic causes. In 70% of the cases the cause is obscure, but in 10% of the cases, defects occur due to environmental factors such as radiation, drugs, chemicals, heat, infection etc. They had their most impact during the time the embryo develops. It is also believed that in 70% of obscure cases a good percentage may be due to an effect of exposure to chemical agents (insecticides, pesticides, paints, etc.) or intake of drugs during early pregnancy. Thus drugs seem play most important role in the environmental factors affecting the baby.
Some of the effects medicines can cause are:

· Smaller baby size (e.g. smoking)
· Limb defects (e.g. thalidomide)
· Addiction (e.g. morphine)
· Brain problems (e.g. alcohol)
· Heart or kidney problems (e.g. alcohol)
· Various malformations e.g. cleft palate.
· Problems with blood flow to the baby (e.g. Anti-inflammatory drugs)
· Behavioural problems (e.g. alcohol)
· Miscarriage (e.g. misoprostol)
· Contractions of the uterus (e.g. castor oil)
· Premature delivery.
· Sometimes problems can be delayed, e.g. stilboestrol given during pregnancy has showed problems with reproductive system during puberty of offspring.

Normally before a drug is released in the market, it is extensively tested – in the lab, on animals and finally on the target population (clinical trials). However, pregnant women and children are compulsorily excluded from such trials, which means that what ever data we have on the role of drugs in pregnancy, is case related and no pharmaceutical company or doctor can support with a foolproof guarantee, the safety of any drug used during pregnancy.

Another important fact to be borne in mind is that for a given medicine, it may be consumed during some part of the pregnancy, but can be hazardous during another part of the pregnancy. e.g. Ibuprofen, may be used with caution in the first or second trimester, but can cause bleeding or delivery problems or even heart problems in the baby if used near term.

Some genetic conditions are also caused by an interaction between the inherited genetic information and the environment such as diet and lifestyle factors. Such conditions are referred to as “multi-factorial” conditions. Examples of such birth defects include cleft lips and palate, hydrocephalus, spina bifida etc. A person will be affected by these conditions if their genetic information means that they are predisposed to the condition, and are exposed to the environmental factor that can “trigger” it. If exposure to the environmental trigger can be avoided, it may be possible to prevent the person being affected with the condition despite genetic make-up.

Some medicines have the ability to prevent or minimize the development of those multi-factorial conditions whose “environmental trigger” is now well known.

The most important ones, where the “trigger” is deficiency of folic acid (Vitamin B9) are:
- Spina Bifida.
- Anencephaly
- Cleft lip
- Cleft palate.

Spina bifida and anencephaly are problems with the development of the spine or brain. Together they are called Neural Tube Defects (NTDs).

Research has shown that 7 out of 10 cases of NTDs can be prevented by increasing the intake of the vitamin B9 (folate) or folic acid prior to and during early pregnancy. Folate is important in the growth and development of new cells and making DNA, especially embryos. It also helps to regulate the level of an amino acid called homocystine.

Folate in pregnancy also lessens the risk of cleft palate and cleft lip by 25 to 50%.

Now the question arises that how much folate is needed before and in early pregnancy?
For most women as a rule, it is necessary to have about 400 – 500 milligrams of folate each day. This can be obtained by eating a folate rich diet and/or taking a low dose folic acid tablet. However, folate will only help in preventing spina bifida or other NTDs if it is being taken at the time of conception and for the first twenty-eight days of pregnancy, or until the neural tube has completely formed. Therefore our advice is to use foloc acid supplements from ONE MONTH BEFORE planning a baby until THREE MONTHS into the pregnancy.

Foods rich in Folate:
- Leafy green vegetables, broccoli
- Wholegrain breads.
- Cereals
- Legumes (peas, dried beans and lentils, peanuts)
- Citrus fruits and juices.
- Asparagus, avocados.

Women are at increased risk if:
- They had a baby with Spina bifida, ancencephaly or other NTDs.
- They themselves have, or have had, a NTD.
- They have a close relative who has, or has had, a NTD.

These women should consult their doctor/foetal anomaly counsellor or genetic counsellor before pregnancy for advice regarding the amount of folate they should take.

Mind + Body + Soul = Individual – The biggest Myth of the century

The biggest myth of the century is that you and me – indeed all individuals are made up of mind, a body and a soul. In other words, we are a sum of three distinct parts. This myth is most evident in the way we treat our illness.
When it comes to health and healing, the modern approach has always been to treat ailments in isolation. The emphasis on treating illness in a purely physical or mechanistic way continues even as new research gives overwhelming evidence of the connection between our psychological aspects and our physical health.
Granted, there is lot of talk about the mind-body-soul connection and most modern physicians understand the psychotic conditions like stress play a role in aggravating certain symptoms. Yet, a few physicians offer life style changes as a first course treatment, proving that they pay only a lip service to the idea of what we call complete wellbeing.
For example, did you know that depression might be linked to nutrition? Recent researches suggest that depression may be caused by inflammation in the brain as a direct result of an imbalanced diet! In fact some psychiatrists are treating depression successfully by getting their patients to increase their intake of Omega-3 Fatty Acids. Yet, anti-depressant pills are prescribed by many doctors at the drop of the hat.
Take another example- of skin care. Skin care is considered to be purely a physical phenomenon. Skin problems are also usually dealt with either physical or physiologically. The idea that our psychology might affect the health of our skin is not so popular. But psycho-dermatology is an established field of medicine that is based on the evidence that our emotional states affect our skin directly. So, does this mean that your stubborn acne might be better managed by altering your emotions? Yet it does! And why just your skin? Evidence are springing up about how emotions are responsible for healing or preventing even critical illnesses such as coronary heart disease, cancer and diabetes.
The incontrovertible truth is that we are not sum of parts. You and me are not a Mind + a Body + a Soul. We are an integrated whole. This mind, body and the soul are terms that only describe the various dimensions of an individual and his/her life and experience.
What does that mean? It means that what we feel, what we think, and what we do make up what we are in totality. It means that being fit and healthy is not just about maintaining a good diet, exercising regularly, and staying in a hygienic environment. To be sure, these are necessary conditions. But by no means they are sufficient. Emotional health, mental health or physical health are misnomers. Health is singular. An illness, whether emotional or physiological is an illness and must not be treated uni-dimensionally.
Based on these evidences modern science is now considering that every disease is psycho – somatic.
Therefore the first step towards achieving complete well being is to break the notion that we are sum of parts. Purge this myth from your life and acknowledge your instincts of being a living, breathing miracle that medical science is only beginning to understand, but which you have known all long. Then only true wellness can be attained.

Food stuff and Doshas - Interrelation

Tridoshas form the fundamentals of Ayurveda treatment. According to ayurveda whole of the human body and the Universe at large are made up of and are governed by these three doshas only viz Vata, Pitta and Kapha. Any disturbance in any one of these components leads to a disease condition and by bringing these in harmony we can cure the disease and lead a healthy life. For this Samanya and Vishesha siddhanta is applied in Ayurveda i.e. The food stuffs which contain a specific guna will increase the respective dosha in the body ( when consumed) and will decrease the opposite dosha. Viz.
Vata foods: Foods containing vayu and little of pitta or kapha strengthen the nervous system but weaken the mucous and circulatory system.
Pitta foods: strengthen circulation but weaken the mucous and nervous system.
Kapha foods: Strengthen the mucous system, weakening nervous system and circulation.
Vata-Pitta foods: Strengthens nervous and circulation at the expense of mucous system.
Vata-Kapha foods: Stengthen nerves and mucous, weakens circulation and increases the concentration of heat.
Pitta-Kapha foods: Promotes circulation and lubrication, weakening the nervous system.
Vata – Pitta-Kapha foods: Promote proper function of all bodily systems. Foods containing all these elements are fresh whole milk, fresh cream, black pepper and fish. The milk and cream must be of the same day’s milking otherwise the vayu and pitta properties are lost, leaving only kapha (the only property left in stored – purchased milk). Whole milk or cream should be taken only after heating to just below theboiling point.
Some of the food stuffs and the doshas to which they are associated are given below:

Avocado - Kapha
Banana – Vata-Pitta
Beets – Vata-Kapha
Brccoli – Vata
Cabbage – Kapha
Carrots – Vata-Kapha
Cauliflower – Kapha
Celery – Pitta
Chestnuts – Vata – Kapha
Chocolate – Pitta
Coffee – Pitta
Corn – Vay –Kapha
Corn flakes – Vayu
Cream – Vata-Pitta-Kapha
Cream cheese – Vata - Kapha.
Curd – Pitta
Date – Vata-Kapha
Escarol – Kapha
Grape fruit – Kapha
Grapes – Vata – Kapha
Greens – Kapha
Honey – Kapha
Kolrabi – Kapha
Lemon – Vata
Lettuce – Kapha
Milk (fresh) – Vata-Pitta-Kapha
Milk (bottled) – Kapha
Mint – Pitta
Mushrooms – Kapha
Oat meal – Vata – Kapha

Olive (ripe) – Vata-Kapha
Onion – Pitta
Parsley – Vayu
Peanuts – Pitta
Pears – Kapha
Peas – Pitta
Pickles (Sour & hot) – Pitta
Potatoes – Pitta
Pulses – Pitta
Rice – Kapha
Salt – Vayu
Soyabeans – Pitta
Spinach – Kapha
Sugar (Raw) – Pitta
Sugar (Refined) – Vata-Pitta
Sunflower seeds – Pitta
Tea – Vata
Tomatoes – Kapha
Turnips – Kapha
Vinegar – Pitta
Walnuts – Pitta
Wheat –Pitta

Thus we see that every food is related to a particular dosha and by consuming the food in precise manner or according to the need we can stay healthy and can also cure small ailments by food only.