Passing Bloody Stool: Why?

Passing bloody stool (per rectal bleeding) means that there is bleeding somewhere along the digestive tract, from the esophagus, stomach, small intestine, large intestine to anus.

There are many possible causes for passing bloody stool. the more common causes include (not a comprehensive list):

- hemorrhoids/piles (may be the most common one)

- anal fissure/fistula

- tumour/cancer in lower part of the bowel (everyone is afraid of this)

- massive bleeding from upper part of the bowel (stomach ulcer/varices/cancer)

- inflammatory bowel disease esp ulcerative colitis

- diverticulitis (in the elderly)

- angiodysplasia (in the elderly)

It's important to note that massive per rectal bleeding from any cause can be life threatening. If someone suspected or known to suffer from per rectal bleeding and is very unstable (giddy, breathless, fainted), then he/she must be sent to a hospital without delay.

     Hemorrhoids: common cause of PR bleeding

 

To find out the cause of bleeding, first we need to consider the nature of the blood. Because of gravity, bleeding occurs at any part of the digestive tract will eventually pass out through the anus. The important points about the nature of the blood are:

- the colour of the blood

- the amount of blood

- is the blood mixed with stool or seperated from stool

The shorter the time the blood in the digestive tract before being passed out, the fresher/more red the blood will be. Thus, if the bleeding point is at the lower part of digestive tract (large intestine, rectum, anus), the fresher the blood will be. The more massive the bleeding is (large volume of blood will flow faster), the fresher the blood will be. The blood will turn dark/black the longer it remains in the digestive tract due to oxidation of iron within the blood.

Example of lower digestive tract bleeding that may give you fresh blood are hemorrhoids, anorectal fistula/fissures (anus/rectum), ulcerative colitis, diverculitis, angiodysplasia, colorectal cancer (large bowel).

Example of massive/heavy bleeding from upper part of digestive tract which may give "not so fresh" bloody stool are stomach/duodenal ulcer or variceal bleeding.

For most bleeding from the upper digestive tract (esophagus, stomach, small bowel), the blood will become black & tarry when being passed out (melena).

     melena stool: black & tarry

For bleeding from the lower part of the large bowel (rectum, anus), the blood usually do not mix with the stool and we can see blood dripping onto the toilet bowl.

For bleeding from higher up from the upper part of large bowel, the blood will usually mix with the stool.

After this, it is important to know whether there are other signs & symptoms accompanying the per rectal bleeding:

- pain when passing stool (usually due to anus fissure, hemorrhoids)

- tenesmus (persistent feeling of wanting to pass stool - usually due to tumour in the rectum)

- change in bowel habit (could be due to ulcerative colitis, tumour)

- abdominal discomfort/bloatedness (could be due to ulcerative colitis, diverticulitis, tumour)

- unexplained weight loss (could be due to ulcerative colitis, diverticulitis, tumour)

- anemia/pale (indicate either chronic little blood loss or sudden massive blood loss)

     Colonoscopy: Colon cancer which is bleeding

From the information gathered above, we can have an idea of where is the bleeding and what cause the bleeding. To confirm the diagnosis, an endoscopy is neccessary. If hemorrhoids or anal fissure is suspected, a proctoscopy should be enough. For lesion in the large bowel, a sigmoidoscopy/colonoscopy will be done. For lesion in the small bowel where the scope can't reach, an X-ray or CT scan with contrast can be done. Whereas for lesion high up in the stomach, duodenum & esophagus, a gastroscopy is a must.

If you have per rectal bleeding, you are advised to seek medical attention from your doctor.

Sudden Face Weakness: Do I Have Stroke?

If someone suddenly has one-sided facial weakness, this is usually due to problems within the nervous system that send electrical message to the group of affected facial muscles. It can be either the brain or the facial nerve.

Facial weakness may also cause difficulty in closing eyes, chewing, eating, drinking, talking and may lead to dry eye and dry mouth.

When we see someone who suddenly develop asymmetry face, most of us will straight away think that he/she must be suffering from stroke. However, there are also other reasons such as Bell's palsy, brain tumour etc.

       Facial nerve & facial weakness

Bell's palsy is not life-threatening. In Bell's palsy, the facial nerve is swollen but the reason is not clearly known though it is related to some viral infection. As the facial nerve run through a tight space around the skull, it will get compressed and injured when it is swollen. Thus, it loses its function and results in weakness of the muscles it controls.

The severity of facial weakness in Bell's palsy differs from mild to severe. It is most obvious when the sufferer is asked to show his/her teeth. It may take weeks to months to recover its strenght depending on the severity. The sooner it improves, the higher the chance that the sufferer will regain full facial muscle strenght. If the weakness persists for months, then there is higher chance that the weakness may not recover fully.

Another more worrying cause of sudden one-sided facial weakness is stroke. Stroke is either caused by blockage of blood vessel that supply the brain (ischemic stroke - more likely) or bleeding in the brain. In stroke, not only the facial nerve is affected, it often involves other muscle groups in the head and limbs as well. Thus, the stroke sufferer may also have one-sided weakness in his/her arm & leg.

       Ischemic stroke

Tumour in the brain or around the facial nerve may compress the nerve and cause facial weakness. As tumour (also bleeding in the brain) will occupy some space in the skull, it will increase the pressure within the skull and produce symptoms such as headache, vomiting, visual disturbance, altered concious level and even coma. This is life threatening and the patient should get immediate medical attention.

       Brain tumour in a CT scan

How to differentiate between Bell's palsy, stroke and brain tumour when someone has one-sided facial weakness?

As a rule of thumb:

If the weakness involves other part of the body other than the face, ie limbs, then it is NOT Bell's palsy, but could be stroke or brain tumour.

If no other part of body is involved other than the face, it could be Bell's palsy, brain tumour but UNLIKELY to be stroke.

If there are symptoms of persistent vomiting, visual disturbance and altered mental status, then it is NOT Bell's palsy, but could be stroke or brain tumour. Generally in stroke, the symptoms occur suddenly but for brain tumour, the symptoms develop gradually. Only a brain scan (CT scan) can differentiate both.

If there is only pure one-sided facial weakness and nothing else (except may be some mild headache), then it is LIKELY to be Bell's palsy.

If you are not sure, see your doctor for proper examination.

For Bell's palsy, doctors may prescribe steroids (prednisolone 1mg/kg or 60mg/day) for 6 days, then taper down the dose for 10 days. This has been shown to reduce facial nerve swelling, reduce the duration and increase the chance of full recovery. It is most effective if taken within 3 days of onset of facial weakness. However, those who do not take steroids also have a chance to recover fully.

Anti-viral drugs can be prescribed together with prednisolone but its effectiveness is still not clear. Eye drops and eye patch can be used especially during sleep to relieve dry eyes.

Sudden Red Patch On Eye White

You wake up in the morning and look into a mirror and notice that one of your eye is red like a monster. Your friend looks curiously into your eye and ask you why your eye is so red but you are not aware of it. How could your eye turn red without you even knowing it?

There are a lot of causes for red eyes, some can be serious and some are not. If there is no preceding trauma/injury to the eye, and no symptoms such as eye pain, blur vision, fever, dry eye, itchiness or major eye discomfort, then there is a high chance that the red eye could be due to subconjunctival hemorrhage.

Conjunctiva is a thin & transparent membrane that cover the sclera (white part of eye) and inner sides of eyelids. It contains small blood vessels which are usually not clearly visible. When the conjunctiva get irritated, infected & inflamed, the vessels will become prominent as shown in conjunctivits. If the vessels break and bleed, it will lead to subconjunctival hemorrhage.

      Subconjunctival hemorrhage

There are a few causes for subconjunctival hemorrhage.

- spontaneous without a reason

- due to increased pressure: coughing, sneezing, straining, vomiting, hypertension

- due to eye injury or trauma, eye-rubbing

- due to bleeding tendency: bleeding disorders, blood thinning medicine

Other than a bright red patch with clear margin, subconjunctival hemorrhage DOES NOT come with eye pain or change in vision (except in trauma). If you have eye pain, eye discharge, blur vision, then it could be something else which could be more serious. If you have eye trauma/injury, you should see a doctor to make sure that there is no other injury. If you have multiple red patches on both eyes, then it could be due to underlying systemic disorder such as bleeding disorder.

Subconjuctival hemorrhage is generally regarded as harmless. There is no particular treatment and it can  cure by itself. The red patch will turn smaller and more pale with time, and usually heal without scar in 1-2 weeks time. If the red patch lasts for more than 2 weeks, or if you have any doubt, then it is advisable to seek medical attention.

High Uric Acid: Do You Need Treatment?

Gout is a disease caused by disturbance in uric acid metabolism which gives rise to high uric acid level in the blood (hyperuricemia).

Gout can affect mainly two body parts:

• joints (gouty arthritis)
• kidneys (urate nephropathy) -which can cause kidney stones and kidney failure

Normal uric acid level in the blood varies between male and female:

• male < 420 mmol/L (7 mg/dl)
• female < 360 mmol/L (6 mg/dl)

If your uric acid level is high, then you have a higher chance of getting gout. The higher the level, the higher the risk, generally.

What if your uric acid level is slightly higher than normal limit? Do you need to get treatment to lower your uric acid level to prevent gout? 

      uric acid needle-like crystals

The most popular medicine to lower uric acid is allopurinol. This medicine can have serious side effects (hypersensitivity, though rare) and may react with other medicines you take concurrently. If you start the allopurinol treatment, you need to continue for your whole life to prevent gouty arthritis and renal impairment.

There are other treatment option like probenecid and an emerging new drug called feboxostat which has shown promising effect. However, the most cost-effective choice is still allopurinol at the moment.

The simple guide to determine whether you need drug treatment to lower your uric acid are:

• Persistent sky high uric acid level > 770mmol/l (13mg/dl) for male and >600mmol/L (10mg/dl) for female
• Three or more episodes of acute gouty arthritis in a year
• Presence of urate nephropathy (urate kidney stones / kidney damage)
• Presence of tophi (chronic tophaceous gout)
• Presence of erosive gouty arthritis (from clinical or X-ray)

      Acute gouty arthritis: red, swollen & extremely painful

      Most common site: first metatarsal phalangeal joint (podagra)

If you have one of these conditions, then you will probably benefit from treatment to lower your uric acid level. If not treated, you stand a higher risk of irreversible joint damage and kidney failure. 

Please take note that not any joint pain is related to gout. The commonest joints involved in gout is:  base of big toe → forefoot → ankle → knee → wrist → elbow → fingers

      Tophus on toe

      Multiple tophi on hands

      Tophi on pinna of the ear

You need to see a doctor to commence allopurinol, as it may precipitate gout attack.

Apart from taking medication, lifestyle changes should not be overlooked:

• Restrict high purine diet: meat, seafood, animal organs
• Restrict high fructose junk food: soft drinks etc
• Weight reduction
• Plenty of fluids intake: 2-3L/day
• Alcohol restriction
• Control co-morbidity (gout-related illness): hypertension, high lipids, high blood sugar

Corticosteroids Equivalent Dose

Equivalent anti-inflammatory doses of different oral corticosteroids

Prednisolone 5mg
is equivalent to betamethasone 750 mcg
is equivalent to cortisone acetate 25 mg
is equivalent to dexamethasone 750 mcg
is equivalent to deflazacort 6mg
is equivalent to hydrocortisone 20mg
is equivalent to methylprednisolone 4mg
is equivalent to traimacinolone 4mg


Note that mineralocorticoid side effects are most marked with fludrocortisone, but are significant with cortisone, hydrocortisone, corticotropin, and tetracosactide (tetracosacrtin). Minerlacorticoid actions are negligible with the high potency glucocorticoids, betamethasone and dexamethasone, and occur only slightly with methylprednisolone, prednisolone, triamcinolone.


Topical corticosteroids:
The potency of topical corticosteroids is determined by

• the extent to which it inhibits inflammation
• the specific modification (esterification) of the steroid molecule e.g. - hydrocortisone (acetate) 1% is mild but hydrocortisone butyrate 0.1% is a potent preparation 
• the formulation
• presence of other ingredients such as urea or salicylic acid which may increase the absorption of the drug 
• occlusive dressings or increasing hydration of the stratum corneum (increases steroid absorption)

POTENCY EXAMPLES

• mild
  • hydrocortisone 0.1-1%

• moderate
  • clobetasone butyrate 0.05%

• potent
  • hydrocortisone butyrate
  • betamethasone valerate 0.1%
    
    
• very potent
  • clobetasol propionate 0.05%

Adult Immunization Schedule 2012

The Advisory Committee on Immunization Practices (ACIP) of United States of America recently release the latest Immunization schedule for adult in 2012.

* As of February 2012

 

For adults with special medical condition:

These schedules will be updated annually, and may differ between every countries. Please consult your local doctors regarding the immunization schedule in your country.