Stomach and its problems

DIEULAFOY'S LESION: A rare cause of gastrointestinal bleeding

Dieulafoy's lesion is an abnormality in a small artery that supplies blood to the gastrointestinal tract, usually in the stomach. The cause isn't known. It occurs most often in middle-aged men.

Dieulafoy's lesion is a rare cause of severe gastrointestinal bleeding that requires emergency medical treatment. Signs and symptoms of bleeding depend on where the lesion is located but may include:

Vomiting blood
Bloody or black, tarry stools
Dizziness or lightheadedness

A doctor may locate the bleeding with endoscopy. In this procedure, a thin, flexible tube with a camera attached is inserted through your mouth or anus, which allows the doctor to see inside your stomach or colon. Treatment of a bleeding Dieulafoy's lesion may include:

Medications injected directly into the lesion through an endoscope
Endoscopic procedures to seal the lesion, such as with heat (cauterization), surgical clips, rubber bands or lasers
Reducing blood flow to the affected artery (embolization) guided by X-ray images of the blood vessels (angiography)


DUMPING SYNDROME

Dumping syndrome is a group of signs and symptoms that develops most often in people who have had surgery to remove all or part of their stomach, or in whom much of their stomach has been surgically bypassed to help lose weight. Also called rapid gastric emptying, dumping syndrome occurs when the undigested contents of your stomach are transported or "dumped" into your small intestine too rapidly. Common symptoms include abdominal cramps and nausea.

Most people with dumping syndrome experience signs and symptoms soon after eating. In other people, they may occur later — one to three hours after eating — and they can range from mild or moderate to severe and debilitating.

Most of the time, dumping syndrome improves on its own without medical treatment, or by adjusting your diet. In more serious cases of dumping syndrome, you may need medications or surgery.

Signs and symptoms

When signs and symptoms occur during a meal or within 15 to 30 minutes following a meal, they may include:

Nausea
Vomiting
Abdominal pain, cramps
Diarrhea
Dizziness, lightheadedness
Bloating, belching
Fatigue
Heart palpitations, rapid heart rate

When signs and symptoms develop later, they may include:

Sweating
Weakness, fatigue
Dizziness, lightheadedness
Shakiness
Feelings of anxiety, nervousness
Heart palpitations, rapid heart rate
Fainting
Mental confusion

Some people experience both early and late signs and symptoms. Conditions such as dizziness and heart palpitations can occur either early or late — or both. No matter when problems develop, however, they may be worse in the aftermath of a high-carbohydrate meal, especially one that's rich in sugars such as sucrose (table sugar) or fructose (fruit sugar).

Some people also experience low blood sugar (hypoglycemia), related to excessive levels of insulin delivered to the bloodstream as part of the syndrome. Insulin influences your tissues to take up the sugar present in your bloodstream.




Causes

In dumping syndrome, food and juices from your stomach move to your small intestine in an unregulated, abnormally fast manner. This accelerated process is most often related to changes in your stomach associated with surgery. For example, when the opening (pylorus) between your stomach and the first portion of the small intestine (duodenum) has been damaged or removed during an operation, the syndrome may develop.

Dumping syndrome may occur in up to 15 percent of people who have had stomach surgery. It develops most commonly one to six months after surgery, and the greater the amount of stomach removed or bypassed, the more likely that the condition will be severe. It sometimes becomes a chronic disorder.

Gastrointestinal hormones also are believed to play a role in this rapid dumping process.

Risk Factor

Several types of stomach surgery increase your risk of dumping syndrome. These include:

Gastrectomy, in which a portion or all of your stomach is removed. It typically involves removing the pylorus.

Gastroenterostomy or gastrojejunostomy, in which your stomach is surgically connected directly to your small intestine about two feet beyond the pylorus, thus bypassing the pylorus. Doctors sometime perform this operation in people with cancer of the stomach.
Vagotomy, in which the nerves to your stomach are cut in order to lower the levels of acid manufactured by your stomach.

Fundoplication, which is an operation sometimes performed on people with gastroesophageal reflux disease. It involves wrapping the upper portion of your stomach around the lower esophagus to apply pressure that reduces the reflux of gastric contents into the esophagus. However, on rare occasions, certain nerves to the stomach can unintentionally be damaged during surgery and lead to dumping syndrome.

Gastric bypass surgery (Roux-en-Y operation), which is often performed in people who are morbidly obese. It surgically creates a smaller stomach pouch that's smaller than the entire stomach, meaning you're no longer able to eat as much as you once did, resulting in weight loss.

Certain underlying conditions also may make you more susceptible to dumping syndrome. These conditions include:
Diabetes

Gastroesophageal reflux disease (GERD), in which the contents of your stomach move back into your esophagus
Zollinger-Ellison syndrome, which causes severe peptic ulcers

In addition, using the medication metoclopramide (Reglan) can increase your risk. This drug is sometimes prescribed to ease nausea, vomiting and heartburn.

When to seek medical advice

Contact your doctor if you develop signs and symptoms that might be due to dumping syndrome even if you have not had surgery. If you've already been diagnosed with this syndrome, keep your doctor informed on how well your treatment is working. Whenever symptoms worsen, talk to your doctor.

Because poor dietary choices can worsen signs and symptoms, your doctor may refer you to a registered dietitian to help you create the most appropriate eating plan. The guidance provided by a registered dietitian may be particularly important if you have lost large amounts of weight due to the syndrome.

Screening and diagnosis

Your doctor can diagnose dumping syndrome by taking a careful medical history and then evaluating your signs and symptoms. If you have undergone stomach surgery, that may help lead your doctor to a diagnosis of dumping syndrome.

Because low blood sugar is sometimes associated with dumping syndrome, your doctor may order a test to measure your blood sugar level at the peak time of your symptoms to help confirm the diagnosis.

Complications

In people with severe cases of dumping syndrome, marked weight loss and malnutrition may occur. Sometimes people who lose a lot of weight may also develop a fear of eating, related to the discomfort associated with the rapid dumping of undigested food. They may also avoid outdoor physical activity in order to stay close to a toilet. Some have difficulty keeping a job because of their chronic symptoms.

Treatment

Most cases of dumping syndrome improve without any treatment, typically in several months to about a year after signs and symptoms begin. However, if they don't improve on their own — or if you want relief from symptoms soon after they appear — your doctor may advise one or more treatment options to slow the emptying of your stomach's contents. The choices for managing dumping syndrome include dietary changes, medications and surgery.

Dietary changes

Adjusting your diet may relieve your symptoms. Here are some strategies that your doctor may recommend:

Eat smaller meals. Try consuming about six small meals a day rather than three larger ones.

Avoid fluids with meals. Drink liquids only between meals.
Change the makeup of your diet. Consume more low-carbohydrate foods. In particular, concentrate on a diet low in simple carbohydrates such as sugar (found in sweets like candy, cookies and cakes). Read labels on packaged food before buying, with the goal of not only avoiding foods with sugar in their ingredients list, but also looking for (and staying away from) alternative names for sugar, such as glucose, sucrose, fructose, dextrose, honey and corn syrup.

Artificial sweeteners are acceptable alternatives. Consume more protein in your diet, and adopt a higher fiber diet.

Increase pectin intake. Pectin is found in many fruits such as peaches, apples and plums, as well as in some fiber supplements. It can delay the absorption of carbohydrates in the small intestine.

Stay away from acidic foods. Tomatoes and citrus fruits are harder for some people to digest.

Use low-fat cooking methods. Prepare meat and other foods by broiling, baking or grilling.

Consume adequate vitamins, iron and calcium. These can sometimes become depleted in the aftermath of stomach surgery. Discuss this nutritional issue with a registered dietitian.

Lie down after eating. This may slow down the movement of food into your intestines.

Even with dietary changes, you may continue to experience severe symptoms associated with dumping syndrome.

Medications

Your doctor may prescribe certain medications to slow the passage of food out of your stomach, and relieve the signs and symptoms associated with dumping syndrome. These drugs are most appropriate for people with severe signs and symptoms, and they don't work for everyone.

The medications that doctors most frequently prescribe are:

Acarbose. This medication delays the digestion of carbohydrates. Doctors prescribe it most often for the management of type 2 diabetes, and it has also been found to be effective in people with late-onset dumping syndrome. Side effects may include sweating, headaches, pallor, sudden hunger and weakness.

Octreotide (Sandostatin). This anti-diarrheal drug can slow down the emptying of food into the intestine. You take this drug by injecting it under your skin (subcutaneously). Be sure to talk with your doctor about the proper way to self-administer the drug, including optimal choices for injection sites. Long-acting formulations of this medication are available. Because octreotide carries the risk of side effects (diarrhea, bulky stools, gallstones, flatulence, bloating) in some people, doctors recommend it only for people who haven't responded to other treatments.

Surgery

Doctors use a number of surgical procedures to treat severe cases resistant to more conservative approaches. Most of these operations are reconstructive techniques, such as reconstructing the pylorus, or they're intended to reverse gastric bypass surgery.

Prevention

You can't prevent dumping syndrome. However, measures such as dietary adjustments may prevent recurrences of your symptoms and minimize their severity.

An extract from Mayo Foundation for Medical Education and Research

Stomach

the stomach is a bean-shaped hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication. The word stomach is derived from the Latin stomachus, which derives from the Greek word stomachos (στόμαχος). The words gastro- and gastric (meaning related to the stomach) are both derived from the Greek word gaster (γαστήρ).


Functions
The stomach is usually a highly acidic environment due to gastric acid production and secretion which produces a luminal pH range usually between 1 and 4 depending on the species, food intake, drug use, and other factors. Such an environment is able to break down large molecules (such as from food) to smaller ones so that they can eventually be absorbed from the small intestine. The stomach can produce and secrete about 2 to 3 liters of gastric acid per day.

Pepsinogen is secreted by chief cells and turns into pepsin under low pH conditions and is a necessity in protein digestion.

Absorption of vitamin B12 from the small intestine is dependent on conjugation to a glycoprotein called intrinsic factor which is produced by parietal cells of the stomach.

Other functions include absorbing water, some ions, and some lipid soluble compounds such as alcohol, aspirin, and caffeine.


The stomach lies between the esophagus and the duodenum (the first part of the small intestine). It is on the left side of the abdominal cavity. The top of the stomach lies against the diaphragm. Lying beneath the stomach is the pancreas, and the greater omentum which hangs from the greater curvature.

Two smooth muscle valves, or sphincters, keep the contents of the stomach contained. They are the Cardiac or esophageal sphincter dividing the tract above, and the Pyloric sphincter dividing the stomach from the small intestine.

The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic (inhibitor) peluxes (anterior gastric, posterior, superior and inferior, celiac and myenteric), which regulate both the secretory activity and the motor activity of the muscles.

In humans, the stomach has a volume of about 50 mL when empty. After a meal, it generally expands to hold about 1 litre of food, but it can actually expand to hold as much as 4 litres. When drinking milk it can expand to just under 6 pints, or 3.4 litres. The human stomach has more nerve endings than the human brain.

Sections
The stomach is divided into four sections, each of which has different cells and functions. The sections are:

Cardia where the contents of the esophagus empty into the stomach.
Fundus formed by the upper curvature of the organ.
Body or corpus the main, central region.
Pylorus or antrum the lower section of the organ that facilitates emptying the contents into the small intestine.

An extract from Wikipedia

Skin Treatment Options

Dermabrasion
From the beginning of time, people suffering from the disfigurement of facial scarring have searched for ways to improve these imperfections. Thanks to refinements of a number of dermatologic surgical techniques, there are several safe, effective procedures available today to improve facial scarring, including dermabrasion or scarabrasion.

What is Dermabrasion?
While more than 100 years old, dermabrasion has enjoyed a resurgence of popularity since the 1960's. The resurfacing technique has been further perfected over the last few decades.

During dermabrasion, or surgical skin planning, the dermatologic surgeon freezes the patient's skin, scarred from acne, chicken pox or other causes. The doctor then mechanically removes or "sands" the skin to improve the contour and achieve a rejuvenated appearance as a new layer of remodeled skin replaces the damaged skin. The new skin generally has a smoother and refreshed appearance. Results are generally quite remarkable and long-lasting.

When is Dermabrasion Indicated?
When dermabrasion was first developed, it was used predominantly to improve acne scars, chicken pox marks and scars resulting from accidents or disease. Today, it is also used to treat other skin conditions, such as pigmentation, wrinkles, sun damage, tattoos, age (liver) spots and certain types of skin lesions. The treatment may also be applied to select areas of deformed skin.
The conditions under which dermabrasion would not be effective include the presence of congenital skin defects, certain types of moles or pigmented birthmarks, and scars from burns.

What Happens Prior to Surgery?
Before surgery, a complete medical history is taken and a careful examination is conducted in order to evaluate the general health of the patient. During the consultation, the dermatologic surgeon describes the types of anesthesia that may be used, the procedure, and what results might realistically be expected. The doctor also explains the possible risks and complications that may occur. Photographs are taken before and after surgery to help evaluate the amount of improvement. Preoperative and postoperative instructions are given to the patient at this time.

How Does the Procedure Work?
Dermabrasion can be performed in the dermatologic surgeon's office or in an outpatient surgical facility. Medication to relax the patient may be given prior to surgery. The area is thoroughly cleansed with antiseptic cleansing agent. The area to be "sanded" is treated with a spray that freezes the skin. Sometimes local tumescent anesthesia can be used. A high-speed rotary instrument with an abrasive wheel or brush removes or abrades the upper layers of the skin and improves irregularities in the skin surface.

What Happens After the Surgery?
For a few days, the skin feels as though it has been severely "brush-burned." Medications may be prescribed to alleviate any discomfort the patient may have. Healing usually occurs within 7 to 10 days.

The newly formed skin, which is pink at first, gradually develops a normal appearance. In most cases, the pinkness has largely faded by eight to 12 weeks. Make-up can be used as a cover-up as soon as the crust is off. Generally, most people can resume their normal occupation in seven to 10 days after dermabrasion. Patients are instructed to avoid unnecessary direct and indirect sunlight for three to six months after the procedure and to use a sunscreen on a regular basis when outdoors.

Chemical Peeling

Chemical peeling is a technique used to improve the appearance of the skin which is typically performed on the face, neck or hands. In this treatment, a chemical solution is applied to the skin that causes it to "blister" and eventually peel off. The new, regenerated skin is usually smoother and less wrinkled than the old skin. The new skin is also temporarily more sensitive to the sun.

Dermatologic surgeons have used various peeling agents for the last 50 years and are experts in performing multiple types of chemical peels. A thorough evaluation by your dermatologic surgeon is imperative before embarking upon a chemical peel.

What Can a Chemical Peel Do?

Chemical peeling is often used to treat fine lines under the eyes and around the mouth. Wrinkles caused by sun damage, aging and hereditary factors can often be reduced or even eliminated with this procedure. However, sags, bulges, and more severe wrinkles do not respond well to peeling and may require other kinds of cosmetic surgical procedures such as a face lift, brow lift, eye lift or soft tissue filler.

Mild scarring and certain types of acne can also be treated with chemical peels. In addition, pigmentation of the skin in the form of sun spots, age spots, liver spots, freckles, splotching due to taking birth control pills, and skin that is dull in texture and color may be improved with chemical peeling.

Chemical peeling may be combined with laser resurfacing, dermabrasion or soft tissue fillers to achieve cost-effective skin rejuvenation customized to the needs of the individual patient. Areas of sun-damaged, precancerous keratoses or scaling patches may improve after chemical peeling. Following treatment, new lesions or patches are less likely to appear. Generally, fair skinned and light haired patients are ideal candidates for chemical peels. Darker skin types may also experience good results, depending upon the type of skin problem encountered.

How Are Chemical Peels Performed?

Prior to surgery, instructions may include the elimination of certain drugs and the preparation of the skin with topical pre-conditioning medications. The patient may be advised to clean the area with an antiseptic soap the day before surgery.

A chemical peel can be performed in a doctor's office or in a surgery center as an out-patient procedure. At the time of treatment, the skin is thoroughly cleansed with an agent that removes excess oils, and the eyes and hair are protected. One or more chemical solutions - an alpha hydroxy acid, such as glycolic acid, salicylic acid, or lactic acid; trichloroacetic acid (TCA); or carbolic acid (phenol) - are used. Dermatologic surgeons are well qualified to select the proper peeling agent based upon the type of skin damage present. During a chemical peel, the physician applies the solution to small areas on the skin. These applications produce a controlled wound, enabling new, refreshed skin to appear. Most patients experience a warm to somewhat hot sensation which lasts about five to ten minutes, followed by a stinging sensation. A deeper peel may require pain medication during or after the procedure.

What Should Be Expected After Treatment?

Depending upon the type of peel, a reaction similar to a sunburn occurs following a chemical peel. Superficial peeling usually involves redness, followed by scaling that ends within three to seven days. Medium-depth and deep peeling may result in swelling and the presence of water blisters that may break, crust, turn brown, and peel off over a period of seven to 14 days. Some peels may require bandages to be placed on part or all of the skin that is treated. Bandages are usually removed in several days and may improve the effectiveness of the treatment. It is important to avoid overexposure to the sun after a chemical peel since the new skin is fragile and more susceptible to complications. The dermatologic surgeon will prescribe the proper follow-up care to reduce the tendency to develop abnormal skin color after peeling.

LASER AND INTENSE PULSED LIGHT APPLICATIONS

WHAT IS A LASER?
Laser stands for Light Amplification by the Stimulated Emission of Radiation. Lasers work by producing an intense beam of bright light that travels in one direction. The laser beam can cut, seal or vaporize skin tissue and blood vessels. The laser has the unique ability to produce one specific color (wavelength) of light that can be varied in its intensity and pulse duration. Ordinary light from non-laser sources is composed of many different colors and appears white. This broad spectrum of light can also be pulsed to a specific duration and varied in intensity as well as the exact range of wavelengths. This allows broad spectrum Intense Pulsed Light (IPL) the ability to specifically treat blood vessels and pigmentation. The wavelength and power output of a particular laser or IPL typically determines its medical application. When the laser or IPL light is directed at skin tissue, its light energy is absorbed by water or pigments found in the skin. Water is found in large amounts in all living cells. Pigments of the skin include hemoglobin, a protein that makes blood red, and melanin, the tan or brown-colored pigment. All three targets absorb laser light of different colors.


WHAT ARE THE BENEFITS OF LASER AND/OR IPL SURGERY?
Lasers may offer you and your dermasurgeon the following general benefits:
Improved therapeutic results
Reduced risk of infection
"Bloodless" surgery with most lasers
An alternative to traditional scalpel surgery, in some cases
Less scarring, in most cases
Precisely controlled surgery, which limits injury to normal skin
Safe and effective outpatient, same-day surgery for many skin conditions

WHAT TYPE OF LASER OR IPL SHOULD BE USED?
Different types of lasers and IPL are used to treat a variety of skin conditions, birthmarks and growths and cosmetic complaints. Presently, no single laser or IPL is capable of treating all skin conditions, but certain lasers can be tuned to a variety of colors of light or coupled to a robotized scanning device to expand their clinical effectiveness. Your dermasurgeon will carefully evaluate your individual condition and suggest the appropriate type of laser and/or IPL system to achieve the best results.

WHO IS QUALIFIED TO PERFORM LASER AND/OR IPL SURGERY?
Experts in skin care, dermasurgeons have extensive training and experience with laser and IPL surgery. In fact, most of the latest advances in laser and IPL technology and its applications were pioneered and refined by dermasurgeons.

WHAT ARE THE COMMON LASERS AND IPL USED IN DERMASURGERY?
CARBON DIOXIDE (CO2) LASER
The CO2 laser system can be used in several ways: "focused" for cutting skin without bleeding; "defocused" for superficially vaporizing skin; and "ultra pulsed" for facial resurfacing. By delivering very powerful, rapid pulsing or scanning of the latest generation of CO2 lasers, dermasurgeons are able to resurface the skin for cosmetic improvement. This technique removes fine lines and wrinkles of the face, smoothes acne scars, and rejuvenates aging and sun-damaged skin as it contours the skin surface.

When the CO2 laser's energy is defocused and not continuous (pulsed), the dermasurgeon can treat warts, shallow tumors and certain precancerous conditions.
When the CO2 laser energy is continuous and focused into a small spot of light, the beam is able to cut the skin. It is used in this way to remove skin cancers, to treat a variety of nonvascular and pigmented lesions and for eyelid operations. This technique is also used to remove warts and for some surgical incisions.

ERBIUM (ER):YAG LASER
The high-powered erbium:YAG (Er:YAG) laser produces energy in a wavelength that gently penetrates the skin, is readily absorbed by water and scatters the heat effects of the laser light. These properties enable dermasurgeons to remove thin layers of aged and sun-damaged skin tissue with exquisite precision while protecting healthy surrounding tissue. The Er:YAG laser is commonly used for skin resurfacing to improve moderate facial wrinkles, mild surface scars or splotchy skin discolorations. Newer Er:YAG lasers have an extended pulse duration that allows them to act in a similar manner to the CO2 laser. Your dermasurgeon is best able to determine which of these lasers, alone or in combination, are best suited to correct your specific concern.

YELLOW LIGHT LASERS
Through the use of an organic dye, short pulses of yellow-colored light are produced. A popular yellow light laser is the pulsed dye laser. Because yellow light is more precisely absorbed by the hemoglobin than other colors, these lasers are effective in the treatment of blood vessel disorders, such as port wine stains, red birthmarks, enlarged blood vessels, rosacea, hemangiomas and red-nose syndrome. Certain yellow light lasers may also be used to treat stretch marks and are safe and effective for infants and children. The krypton and Nd:YAG lasers are dual light systems. The uses of the yellow light are similar to those already described.
The green light, in contrast, is used for the treatment of benign brown pigmented lesions, such as café-au-lait spots, the "old age" spots commonly found on the backs of the hands and lentigines or freckles. Green light lasers are also used for the treatment of small blood vessels on the face and legs.

RED LIGHT LASERS
The red light spectrum produced by the ruby or alexandrite light laser is emitted in extremely short, high-energy pulses due to a technique known as Q-switching. The Q-switched ruby or alexandrite laser systems were initially used to remove tattoos, but are now commonly used to treat many brown pigmented lesions, such as freckles or café-au-lait spots.

When the pulse duration of the ruby or alexandrite lasers is lengthened, it is effective in removing unwanted hair for long periods of time, sometimes even permanently.

OTHER LASERS
THE Q-SWITCHED NEODYMIUM YAG (ND: YAG)
Delivering infrared light, it is used to remove tattoos and deep dermal pigmented lesions, such as nevus of Ota. This laser can also be tuned to produce a green light for the treatment of superficial pigmented lesions like brown spots, as well as orange-red tattoos.

KTP
The KTP emits a green light and is capable of treating certain red and brown pigmented lesions. When the pulse duration is lengthened, the Nd:YAG laser is also effective in removing hair and an inflammatory condition termed pseudofolliculitis barbae for months and sometimes permanently. This is particularly useful in the treatment of dark-skinned patients.

NEW TECHNOLOGIES: NON-ABLATIVE LASERS AND LIGHT SOURCES
Instead of heating and removing the top skin tissue, non-ablative (non-wounding) lasers work beneath the surface skin layer to improve skin tone and texture and minimize fine lines with few side effects and a speedy recovery. Light-based devices that produce a broad spectrum of light (wavelengths) with computer-controlled parameters of energy delivery (Intense Pulsed Light, or IPL) can be adjusted according to a patient's skin type and condition. This technology is primarily used for the treatment of benign red and brown lesions, hair removal and facial skin rejuvenation.

OTHER APPLICATIONS: HAIR REMOVAL AND LEG VEINS
Laser technology is presently being utilized for efficient and long-lasting body hair removal. The laser energy causes thermal injury to the hair follicle, stunting hair growth. Several laser hair-removal systems, including the diode laser, the long-pulsed alexandrite and Nd:YAG lasers and the IPL, are being used successfully with long-lasting results.

Until recently, lasers were used primarily for superficial facial veins. Thanks to the newest technologies, leg veins may be effectively treated with a variety of lasers and intense pulsed light systems.

Adapted from: Merck & Co. Inc