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Constipation: Causes, Investigations & Treatment

  • What is Constipation

Most common complaint seen in day to day clinical practice is Constipation. Most frequently patient complain of difficult, infrequent or incomplete defecation. It is difficult to define it as there is wide range of normal bowel habit. More than 90% of population have at least three bowel movements per week.But frequency is not the only criteria as most patients who complain it have a normal frequency of defecation. Most commonly these patients complain of hard stools, excessive staining, a sense of incomplete evacuation and lower abdomen fullness

  • Causes

Usually due to less fluid intake, low fibre diet and decreased colonic transit time.
Recent onset may be due to colonic obstruction. Reason for same may be colorectal cancer, ischemic stricture, diverticular disease. Painful anal spasm which may be due to anal fissure or painful hemorrhoids
Most common cause of chronic constipation is irritable bowel syndrome with constipation predominant. Medical causes include hypothyroidism, hypercalcemia. There are some medications which on long term can cause constipation. Slow colonic transit time is common

  • Investigation

Colonoscopy is advised to rule out mechanical cause such as colonic stricture or malignancy especially in old age patients and with recent history associated with anorexia and weight

  • Constipation Treatments

Lifestyle: Regular time for defecation is important. Always respond to defecatory urge. Physical activity should be encouraged for those who have inactive lifestyle.The drugs which cause it should be avoided
Psychological Support: It can be result of emotional disturbance and can be aggravated by stress. Counselling is required for these patients
Fluid Intake: Less fluid intake causes salt and water absorption by the large intestine,it causes passage of small, hard stools. Thats why patient is encouraged to take plenty of fluids
Laxatives: Two types, Bulk laxatives and osmotic laxatives

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Gallstones or Cholelithiasis


Gallstones or cholelithiasis is most common diagnosis for acute right upper abdomen pain. It is the most common cause of Laparoscopic abdominal surgery

  • Gallbladder stone reason/ What Causes Gallstones

There are many theories about the formation of gallstone. But there is no preventive method. 80% of stones contain cholesterol while rest 20% have calcium and bilirubin salts. It is said that too much cholesterol secreted by liver which bile cannot dissolve causes formation of cholesterol stones. Pigment or bilirubin salt containing stones are formed if too much bilirubin is secreted. However there is no special gallbladder stone diet which can prevent there formation

  • Gallstones symptoms

Gallbladder pain or biliary colic is mild to moderate in intensity, localized to right upper abdomen and occur dut to stone at neck causing obstruction.Jaundice can occur if edema at GB neck causes external biliary obstruction.Fever develop if it becomes a pyocele

  • Complications

Distended gallbladder due to impacted stone at neck causes pain, also called as mucocele gallbladder.Gallbladder infection in mucocele is called as pyocele gallbladder.Repeated inflammation causes contracted gallbladder. When the stone moves through the cystic duct into CBD can cause jaundice, cholangitis, pancreatitis. Gallstone are risk factor for gallbladder cancer. however the incidence rate of cancer is very less

  • Gallstones Surgery

The standard treatment for gallstone is complete removal of gallbladder called as cholecystectomy. It is a day care surgery. Patient can be discharged from the hospital on same day of surgery, and from next day patient can do all day to day activities

  • Gallbladder removal side effects

There is no effect on digestion after gallbladder removal.It may be difficult to digest excess fat for initial 2-3 months. After this period patient can have normal diet
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Gallbladder Polyps: Are These Indications for Gallbladder Removal

What are Gallbladder polyps

Gallbladder polyps are gallbladder wall elevations that project into the lumen. Commonly detected on ultrasound done for other symptoms. Incidence vary from 0.3 to 9%
As the incidence of polyp is more and chances of malignancy is rare, selective surgery is done for these patients and should be counselled accordingly

Symptoms of Gallbladder polyps

As the gallbladder polyp are attached to gallbladder wall and are non-mobile these do not cause any symptoms. Large polyps because of there size and twisting effect or when change into cancer may cause pain

Gallbladder Polyps
Gallbladder polyps
Diagnosis of Gallbladder polyps

Ultrasound abdomen is the most common investigation for diagnosis.It will detect the number and size of polyp. CECT abdomen is done when USG show suspicious of gallbladder cancer

Indication of Surgery

The only indication for surgery in gallbladder polyps is risk of cancer. It is said that risk of cancer is high in polyp size more than 10mm, single polyp and sessile polyp
For Polyp less than 6mm follow up ultrasound is done at 1, 3 and 5 year. For polyp 6-9 mm ultrasound is done at 6 months, 1,2,3,4 and 5 year; If during follow up increases by 2mm or more cholecystectomy is advised
For polyps 6-9mm if there are risk factors for gallbladder malignancy like age > 50 years, sessile polyp, indian ethinicity, PSC then also cholecystectomy is advised

Surgery for gallbladder polyp

Laparoscopic cholecystectomy is the standard surgical procedure for gallbladder polyp. Advantage of laparoscopy surgery being early recovery and discharge from the hospital. If investigations suggest cancer doubt in polyp then it should be treated like gallbladder cancer. Intra-op frozen section should be sent from suspicious area and should proceed accordingly

Consult Dr Amit Jain MS MCh (GI Surgery) for Gallbladder ployp management. Call us at 7351088686 for your queries.

Laparoscopic Surgery: Indications In Gallbladder Disease

  • Laparoscopic Surgery for Gallstone

Laparoscopic Surgery
Laparoscopic Surgery for Gallstone

Gallstones is the most common surgical gallbladder disease. It is the most common indication for laparoscopic surgery for abdomen disease.USG abdomen is the best investigation for diagnosis of gallbladder stones. Most commonly patient present with biliary colic.The standard treatment for gallstones is laparoscopic cholecystectomy.Gallstones can cause various complications like jaundice, cholangitis, pancreatitis. There is no role for medicine in the management.Laparoscopic cholecystectomy is a day care surgery in which patient is operated early in the morning and can be discharged on same day by evening. From next day onwards patient can do all his day to day normal activities. There is no special diet after gallbladder  removal.Patient has to avoid excess fat in the diet for next 2-3 months post-surgery

  • Laparoscopic Surgery for Gallbladder Cancer

It is the surgical gallbladder disease which if detected early and treated carries a good prognosis. Most common symptom of gallbladder cancer is pain right upper abdomen along with anorexia and weight loss. Patient can have jaundice if gallbladder mass most likely at neck compress the biliary symptom.If there is doubt of gallbladder cancer on ultrasound CECT abdomen should be done. There is no role of FNAC if the gallbladder cancer is resectable. The standard surgery for gallbladder cancer is radical cholecystectomy in which gallbladder is removed along with liver wedge and standard lymphadenectomy is done. Earlier cancer surgery was not done laparoscopically in fear of port site metastases. Now we have sufficient data in literature which supports that even cancer surgery can be done laparoscopically with early benefits of minimally invasive approach and long term same survival rate compared to open surgery. Gallbladder cancer surgery is also being done laparoscopy in early stage cancers

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Symptoms of Gastrointestinal Cancer

  • Vomitting

It occur when there is obstruction in the gastrointestinal tract. Obstruction distal to the bile duct opening causes billious vomitting. Obstruction proximal to it causes non-billious vomitting.Primary stomach cancer or small bowel cancer casues vomitting due to intrinsic mass which compromise the lumen. Gallbladder mass can cause external compression over the duodenum and antro-pyloric region resulting in gastric outlet obstruction

GI Cancer Symptoms
  • Dysphagia

Early and Common symptom of esophagus cancer. In patients with esophagus cancer patients have initial dysphagia to solid foods and gradually progress to liquid. This progressive dysphagia is indicative of any progressive mass lesion in the esophagus which is compomising the esophagus lumen and causing dysphagia

  • Jaundice

It occur when there is obstruction in the Common bile duct. Most common symptom of hepato-biliary gastrointestinal cancer symptom.This obstruction can be intrinsic due to bile duct cancer. It may be extrinsic due to external compression such as Gallbladder mass or pancreatic head mass causing external compression over the CBD. patient present with features of obstructive jaundice such as pale colored stool, dark urine and pruritus.

  • Melena

It is passage of black tarrish colored stool. Melena indicate slow bleed in the GI tract. This bleed can originate at any site along the GI tract. Cancer stomach and peri-ampullary cancer and right sided colon cancer have a tendency to bleed. Sometimes patient have occult bleed and present with feature of anemia such as weakness/tiredness

  • Hematochezia

It is the passage of fresh blood per rectum. symptom of lower gastrointestinal tract cancer that is colo-rectal cancer

  • Anorexia and Weight Loss

These are common symptoms of any malignancy in our body

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Multispeciality Gallbladder Cancer Management (Oncologist)

Team work of Cancer Doctor or Oncologist for Gallbladder Cancer

Gallbladder Cancer Management is team work of GI Oncosurgeon, GI Oncologist, Gastroenterologist and Intervention radiologist.Once patient is diagnosed to have gallbladder cancer further management depend on pre-operative staging of the cancer

  • Role of GI Oncosurgeon in Gallbladder Cancer Management
Gallbladder Cancer

If the tumor is resectable, first line of management is surgery. The standard surgical procedure performed for gallbladder cancer is radical cholecystectomy. In this surgery gallbladder is removed along with liver bed and lympadenectomy is done. Staging laparoscopy is first step. There is high incidence of metastases which are missed on pre-operative imaging, which can be detected on staging laparoscopy and morbidity of long incision can be avoided

  • Role of GI Medical Oncologist in Gallbladder Cancer Management

If the cancer is metastatic on imaging then palliative chemotherapy is given. For locally advance cancer but not metastatic pre-operative chemotherapy is given to downstage the tumor and make it resectable.Once cancer seems resectable surgery is done
Chemotherapy is given in the post-op period if the tumor is beyoned certain stage

  • Role of Gastroenterologist in Gallbladder Cancer Management

Patients who are not surgical candidates either because tumor is locally advanced or metastatic or poor peformance status, these patients if have jaundice or vomitting require endoscopic palliation. Jaundice occur when the tumor compress the biliary system and vomitting occur either due to antro-pyloric or duodenal obstruction. Endoscopic Biliary and duodenal stenting is done in these patients. Jaundice and vomitting are relieved after stenting in these patients

  • Role of Intervention Radiologist in Gallbladder Cancer Management

There role comes when palliative endoscopic biliary stenting is not possible because there is complete blockage of biliary system. In these patients percutaneous transhepatic biliary drainage is done to relief jaundice

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Gastroenterologist: Role in Gastro Intestinal Cancer Sypmtoms Management

  • Best Palliative Care by Gastroenterologist for Advance GI Cancer

Surgery is the treatment of choice in gastrointestinal cancers if the tumor is resectable and patient is fit for surgery. Gastroenterologist play important role if the tumor is advanced and metastatic. These patients require treatment for there symptoms. Best way of palliation of symptoms is minimally invasive approach

Role of Gastroenterologist in GI Cancer
  • Palliation of Upper GI Cancers Symptoms by Gastroenterologist

Dysphagia is the most common symptom of esophageal cancer and the best way of palliation is endoscopic placement of esophagus stent across the site of obstruction.In similar way in patients of stomach cancer and duodenal cancer who have gastric outlet obstruction and have vomitting, stent can be placed across the obstruction site and vomitting can be relieved
Patients of esophagus and stomach cancer can present with hematemesis or melena. It indicate tumor site bleed. Many a times these bleeds can be controlled endoscopically

  • Palliation of Lower GI Cancer Symptoms by Gastroenterologist

Growth in the colon or rectum can cause bowel obstruction.Many a times these patients present in emergency with features of large bowel obstruction such as abdomen distension, vomitting, not passage of flatus and motion. When investigated further are found to have advanced colo-rectal cancer. In these patients endoscopically stent can be placed and obstruction can be relieved. A major surgery can be avoided in these patients

  • Palliation of Hepato-biliary Cancer symptoms by Gastroenterologist

Most common hepato-biliary cancer symptom which require palliation is jaundice. Jaundice is either due to primary cancer such as cholangiocarcinoma or it may be caused by external compression by nearby organ malignancy. Gallbladder neck mass, periampullary cancer, pancreatic cancer are common GI malignancy which can cause jaundice.Endoscopic internal biliary stenting is best palliation for these patients

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Gastrointestinal Cancer: An Overview

Gastrointestinal CancerThe incidence of gastrointestinal cancer is increasing. Reason being change in lifestyle, dietary habits, increased alcohol intake and smoking.The prognosis of gastrointestinal cancer patients is good if it is detected early and treated at early stage.Anorexia and weight loss are common symptom in cancer patients, along these symptoms with some GI symptoms if present should not be ignored and doctor should be consulted. There are various screening programmes for early detection of colo-rectal and liver cancer. These programmes are done for high risk patients. Screening Colonoscopy is done for patients with inflammatory bowel disease, family history of colo-rectal cancer diagnosed at early age. Regular ultrasound is done in chronic liver disease patients. Neo-adjuvant therapy for locally advance cancer of esophagus, rectum and pancreas has shown good result. Pre-operative biliary drainage is done in patients with high bilirubin who require liver resection

  • Upper Gastrointestinal Cancer

It include cancer of the esophagus, stomach, duodenum and small intestine.Dysphagia, Vomitting,melena are common symptom. Upper GI Endoscopy is helpful for diagnosis. CECT chest and abdomen for staging.

  • Lower Gastrointestinal Cancer

Cancer of the colon and rectum are lower gastrointestinal cancer. Most common symaptoms are altered bowel habits, blood in stool. Diagnosis is made by Colonoscopy. CECT abdomen for staging.MRI is done for cancer rectum There is role of Neoadjuvant therapy in locally advance rectal cancer.Surgery is the treatment of choice if cancer is resectable

  • Hepato-Biliary GI Cancer

It include cancer of the liver, gallbladder, bile duct and pancreas. Patient have symptom of right sided pain abdomen with jaundice. CECT abdomen along with MRCP is helpful to delineate biliary anatomy

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Ulcerative Colitis Management

Ulcerative Colitis
Ulcerative Colitis

Ulcerative colitis is inflammatory condition of large bowel which starts from the rectum amd involves in a retrograde fashion the proximal large bowel. Rarely it involves the small bowel. The most common symptom is diarrhoea. Biopsy taken during colonoscopy done by gastroenterologist confirms the diagnosis. The cause of ulcerative colitis is unknown. It has been postulated that it may be caused by interaction between patient genetic susceptibility and the environment. The course of the disease is characterized by period of exacerbation of symptoms and remission. The remission of symptoms may be spontaneous or may be due to medicine. Because of transmural  nature of disease it may lead to complications like abscess formation, fistula to orther organs and bowel stenosis. Long term ulcerative colitis is risk factor for bowel cancer

  • Indications for Surgery in Ulcerative Colitis
  • Emergency Indications
    Toxic Megacolon
    Fulminant disease activity not responsive to maximal medical therapy
  • Elective Indications
    Complications of Medical therapy for ulcerative colitis
    Frequent remission despite maximal medical therapy
    Cancer/Intestinal Dysplasia
    Growth retardation in children
Surgery for Ulcerative Colitis

Emergency surgery
Total abdominal colectomy with Hartman procedure or mucus fistula and end ileostomy is done. Once patient condition improve rectum is removed and restoration is done using ileal pouch

Elective Surgery
It can be done in one stage or two stage. Surgery done is total procto-colectomy in which whole of large bowel and rectum are removed. After that a pouch is created from distal part of ileum and this pouch is anastomosed to anal canal. The whole procedure is called as total procto-colectomy with ileo-anal pouch anastomoses.This can be done as a single time surgery. In high risk patients who are on steroids a diverting loop ileostomy is also created. In these patients ileostomy is closed after 4 weeks

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An Approach to Jaundice Patient


Yellowish discoloration of body mainly sclera of eye is jaundice. It occur due to accumulation of bilirubin pigment in the body. Bilirubin pigment is formed after destruction of old red blood cells in the body and after that it is secreted through bile in to stool. Hyperbiliruninemia occur either due to excessive production because of excessive hemolysis. It also occur if there is obstruction in the passage of bilirubin pigment through liver in to small intestine

  • Blood Investigations

The most common blood investigation done is Liver Function Test. Bilirubin is raised in these patient. In case of obstructive jaundice conjugated part of bilirubin is raised while in hemolysis or other medical cause unconjugated bilirubin is raised. If the cause is hepatitis then enzymes SGOT/SGPT are also raised. Serum alkaline phosphate is marker for obstructive jaundice
Uncojugated bilirubin is raised in Hepatitis patients. Most common cause of hepatitis are alcoholic hepatitis, Viral hepatitis and steaohepatitis. Most common viral infections which cause hepatitis are Hepatitis A, E, B and C infection. Blood test for the presence of these infections should be done in case of acute hepatitis
Total Leucocyte counts is raised in patient with cholangitis. Renal function tests should be done

  • Radiological Investigations in Jaundice Patient

The most common first investigation done is Ultrasound abdomen. The dilatation of biliary channels on ultrasound suggest biliary tract obstruction. The level of bile duct dilatations indicate the site of obstruction. CBD stones or mass can be visualized on ultrasound as cause of obstruction
MRI/MRCP is more helpful to delineate biliary anatomy before any intervention. There are guidelines which recommend EUS in these patients before ERCP

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