A study on management of hemorrhoids: Comparison between conservative management and injection sclerotherapy

Background: Hemorrhoidal disease is one of the most common anorectal conditions encountered in daily practice for centuries. Conservative management of hemorrhoids (with oral diosmin, calcium dobesilate cream local application) and injection sclerotherapy with 3% polidocanol-both are very commonly practiced, cost effective, and outpatient department-based management of hemorrhoids which bear rare adverse effects. Comparative efficacy of injection sclerotherapy and conservative management in cases of hemorrhoids is still confusing and contradictory to each other according to different studies. Aims and Objectives: This study was conducted to compare the effectiveness between conservative management of hemorrhoids and injection sclerotherapy. Materials and Methods: This institution-based experimental study done over 74 patients of first- and second-degree internal hemorrhoids. Thirty-seven patients were randomly selected and managed with conservative management, and the rest with injection sclerotherapy. Treatment responses were assessed after 3 weeks and in unsatisfactory responses, treatment was repeated for another 3 weeks. Reassessment was done after 6 weeks and 6 months. Results: This study demonstrated that both injection sclerotherapy and conservative management had improved per rectal bleeding after 3 and 6 weeks of treatment, but the former had a significant edge over the counterpart after 6 months of treatment (56.8% vs. 35.1%, P = 0.002). In case of reduction of hemorrhoidal mass – injection sclerotherapy had significantly better outcome in all the follow-up visits, that is, 3 weeks (54.1% vs. 13.5%, P = 0.001), 6 weeks (70.3% vs. 35.1%, P = 0.008) and 6 months (59.5% vs. 27.0%, P = 0.003). Injection sclerotherapy had superior overall treatment outcome after 6 weeks of treatment (73% vs. 45.9%, P = 0.04) and long-term periods (56.85% vs. 27%, P < 0.01). Conclusion: Injection sclerotherapy shows significantly better and long-lasting improvement in symptomatic hemorrhoids in comparison to conservative management which is mainly able to limit per rectal bleeding only for a short period of time.

Myocardial metabolism: pharmacological manipulation in myocardial ischaemia.

Acute myocardial ischemia may result in diverse outcomes ranging from asymptomatic episodes to frank myocardial infarction. Reperfusion therapy becomes the mainstay of treatment of patients with evolving MI and provide practical approach for salvage of ischemic myocardium. Favorable modulations of metabolic events during and after ischemia results in increased myocardial salvage in reperfused myocardium. The use of GIK showed great advantage in enhancing myocardial salvage in patients with AMI. Use of other metabolic agents show great promise in experimental studies and merits further evaluation in human trials. Metabolic modulation of ischemic myocardium continues to be a unique and untapped approach to favorably effect ischemic myocardium. Metabolic adjuncts can be employed to lessen ischemic injury and thereby enhance the salutary effects of reperfusion. The use of metabolic manipulations which enhance glycolytic pathways and inhibit potentially noxious fatty acid intermediates may also offer a noble approach for the protection of transiently ischemic myocardium in patients with coronary artery disease. And one thing is certain, that is -- agents that modify myocardial metabolism in disease states have definitely enhanced the therapeutic armamentarium to fight the problem and improve the well being of the patients.

High sensitive C-reactive protein: a novel biochemical markers and its role in coronary artery disease.

A series of prospective studies provide consistent data documenting that mild elevation of baseline levels of hs-CRP among apparently healthy individuals is associated with higher long-term risk for future cardiovascular events. This predictive capacity of hs-CRP is independent of traditional cardiovascular risk factors and offers a prognostic advantage over measurement of lipid alone. PHS and CARE trial suggest that the increased risk associated with systemic inflammation may be modified with certain preventive therapies and that inflammatory marker specifically hs-CRP may help to identify those who would benefit most from these pharmacological intervention. hs-CRP is the novel and evolving biomarker which provides a most useful predictive indicator for subsequent cardiovascular events. Based on various studies, increased hs-CRP levels in patients with high risk cardiovascular disease without documented CAD warrant treatment with statin even if LDL-C levels are within target range. Patients with documented CAD and high hs-CRP levels should be followed, and there risk factors should be managed aggressively.

Pseudoaneurysm following lateral wall myocardial infarction.

Pseudoaneursym (PA) formation of left ventricle (LV) following acute myocardial infarction (AMI) is uncommon and is usually believed to be associated with a grave prognosis. We describe a case of 55 year old male patient presented with AMI and heart failure with a systolic murmur later diagnosed to have PA of the lateral wall of LV on echocardiography (transthoracic and transesophageal, TTE andTEE). Cardiac MRI and coronary angiogram (CAG) were performed. CAG showed 60% lesion at origin of major obtuse marginal artery (OM1). The patientwas advised surgical treatment, but he refused and took discharge against medical advice on 27th dayof admission on stable condition.

The newer unconventional indications of permanent pacemakers.

In recent years, the indications for permanent pacemakers have expanded. The interest has focussed on hypertrophic cardiomyopathy, dilated cardiomyopathy and a new entity called hypertensive hypertrophy with cavity obliteration (HHCO). Pacemaker therapy is establishing itself for the prevention of atrial fibrillation. Pacing for neurocardiogenic syncope with newer pacing mode has encouraging datas. Pacemaker for long QT syndrome, after cardiac transplant and for haemodynamic improvement in occasional cases of first degree atrio-ventricular block is getting attention. The AHA and ACC guidelines updated in 1998 for implantation of cardiac pacemakers, now include several of these newer indications.

Current understanding of pathogenesis of coronary artery disease and its future implications.

Coronary artery disease (CAD) is the most important cause of morbidity and mortality in a population. Percutaneous coronary intervention and coronary artery by-pass grafting have greatly changed the treatment of CAD, still many questions remain unanswered. Atherosclerosis is a normal consequence of ageing but some patients may experience it at an earlier age. As regarding pathogenesis of atherosclerosis, it is described often as a focal process which is diffuse in nature primarily involving the vessel intima. Salient features of 'lesion prone areas' in atherosclerosis include increased endothelial permeability to an intimal accumulation of plasma proteins, including albumin, fibronogen and LDL. The clinical expression of atherosclerotic disease activities is determined by pathologic events leading to coronary thrombosis. A vulnerable plaque has the characteristics of: Extracellular lipid pool occupies a large proportion of overall plaque volume, the fibrous cap which separates the lipid core from luminal blood is thinner within, and high macrophage density. Typically these plaques cause < 50% cross-sectional stenosis of the artery. The contribution of CAD is clearly of both genetic and environmental in origin. An increase in shedding of cell adhesion molecules may be a characteristic of atherosclerotic lesion. There is also suggestion that plasminogen activation inhibitor type I (PAI-1) has an important role in atherogenesis. Angiogenic growth factors and their endothelial receptors function as major regulators of blood vessel formation. Thereapeutic angiogenesis can be achieved by exogenously adding VEGF and/or other angiogenic growth factors.

Dilated cardiomyopathy in non-specific aortoarteritis.

Out of 195 cases of Takayasu's arteritis who presented in our institute between January 1988 and December 1997, 12 (5.58%) had dilated cardiomyopathy. Age of these patients ranged from 10 to 30 years (17.25 +/- 5.30 years) and male-female ratio was 1:11. All the cases had cardiovascular system features (dyspnoea, oedema, palpitation, angina, etc. but without hypertension), three had central nervous system features (headache, vomiting, convulsion etc.) and all had general systemic features like weight loss, malaise, fever, arthralgia etc. Electrocardiography, chest X-ray and echocardiographic findings were consistent with dilated cardiomyopathy. Haemodynamic findings showed raised left ventricular end-diastolic pressure and pulmonary capillary wedge pressure in all; raised pulmonary artery pressure, pulmonary vascular resistance, right ventricular pressure and right atrial pressure in 6, 6, 4 and 2 cases, respectively; reduced left ventricular peak systolic pressure in 10 cases but central aortic pressure and systemic vascular resistance in all the cases were within normal limits. Angiography showed type I, II and III involvement in 7 (majority), 3 and 2 cases, respectively. Coronary and pulmonary angiography were normal and left ventricular angiography showed poor left ventricular systolic function in all the cases. Histopathological study (on 3 autopsy cases) showed non-specific inflammation of myocardium with lymphocyte/mononuclear cell infiltration and normal coronary vessels. So, dilated cardiomyopathy in Takayasu's arteritis is not rare, though not much reported, and can influence the prognosis of aortoarteritis cases.

Coronary artery lesions in Takayasu's arteritis--clinical and angiographic study.

Two hundred and twenty five patients of Takayasu's arteritis were studied over 13 years. Male:Female ratio was 1:7. Mean age of the study population was 19 +/- 4 years. Of these 225 patients, 75 patients had symptoms and/or signs of cardiac involvement and these patients were subjected to coronary angiography. Significant coronary artery occlusion (i.e. more than 50% narrowing of luminal diameter) was present in 9 patients. Incidence of coronary artery lesions in Takayasu's arteritis is 12% in this study. The proximal segments of coronary arteries were involved while the distal segments were spared. Out of 34 patients with angina pectoris, only 3 patients had significant coronary arterial narrowing.

Aortoarteritis involving supra-aortic trunks: a profile of six cases.

Six patients (2 male, 4 female; age range 24 to 36 years) with aortoarteritis involving the supra-aortic trunks were investigated and surgically managed by bypass graft with either preclotted dacron or polytetrafluoroethylene (PTFE) in an urban institute. There has been no mortality and post-operative functional recovery has been satisfactory in all the cases.

Significance of exercise induced increase in the diastolic pressure as an indicator of severe coronary artery disease.

A total of 100 patients were studied for the diastolic blood pressure response to treadmill exercise testing. No change in the diastolic pressure or lowering of the pressure was considered normal response. Seventy-four patients had normal and 26 patients had abnormal diastolic blood pressure response. Forty patients underwent coronary angiography. Fifty-five per cent of the patients with normal diastolic pressure response had normal coronaries compared to 20% with abnormal response. Eleven per cent with normal response and 40% with an abnormal response had triple vessel disease whereas 10% with abnormal response had left main coronary artery disease. Exercise induced ST segment depression was almost equal in both groups. Hence it can be concluded that abnormal diastolic pressure response to treadmill exercise testing is a fairly good indicator of coronary artery disease irrespective of ST segment changes.

Hypertension in the young in eastern India.

Three hundred and forty-one young hypertensives in the age group of 18-30 years were evaluated over a 7-year period. Essential hypertension constituted the single largest group (35.8%). Renal pathology was the most common cause of secondary hypertension (26.4%). Congenital coarctation of the aorta and endocrine causes accounted for 14.1 percent and 3.2 percent cases of secondary hypertension, respectively. A strikingly high incidence of nonspecific aortoarteritis (20.1%) was a distinguishing feature amongst secondary causes. Aortoarteritis was the commonest cause of renal artery stenosis. Renal angioplasty was performed in 11 patients with refractory hypertension. Forty percent of the patients achieved post-angioplasty control of blood pressure without drugs; in 25 percent, the blood pressure became easier to control. Restenosis was detected in 4 cases over 18-24 months of follow-up.

Reuse of pacemaker.

Implantation of a permanent pacemaker is an expensive proposition for the poor patients of our country. Many patients on permanent pacemaker die prematurely due to diseases or conditions not related to pacemaker function. The purpose of this study was to reuse these pacemakers after thorough cleansing and proper sterilisation in other suitable patients and compare the efficiency of the reused pacemakers with that of newly implanted ones. Between April 1979 and April 1992, 642 patients implanted with reused pacemakers were studied. The study population consisted of patients ranging in age from 15-85 years and included patients of both sexes (M:F = 4:1). The mean period of follow-up was 7.5 +/- 5.6 years. Removal and reimplantation of the pulse generators was carried out after obtaining the State Government's approval, informed consent of the donors, relatives and recipients. The functional status of the pulse generators was tested by a "pacing system analyser". The clinical indications for reuse were chronic complete heart block, symptomatic bifascicular heart block, sick sinus syndrome and chronic complete heart block with congestive heart failure, in decreasing order of frequency. In terms of morbidity and mortality, the efficacy of reused pacemakers was highly comparable with that of newly implanted ones. The infection rate in cases of reuse from dead patients was comparable to that in cases of new implantation. However, pacemakers reused in the same patient showed a high rate of infection. With the aid of newer generations of antimicrobials, infection when matched with efficacy and economy (of reuse) does not seem to be a major factor against pacemaker reuse.

A study of inferior vena cava obstruction.

Inferior Vena Cava obstruction as a major cause of hepatic venous outflow block is not so common. A prospective study of 20 cases gave us an opportunity to device a management protocol for this disorder. Out of 20 cases we had studied, 12 had only inferior Vena Cava obstruction while rest of the 8 cases had both hepatic vein and IVC blockade. However, balloon cavoplasty showed remarkable results with substantial clinical and haemodynamic improvement in cases with isolated IVC obstruction. Therefore, we suggest that patients with IVC obstruction should be actively managed with Vena-cavography followed by cavoplasty. Treatment of Hepatic venous obstruction along with IVC obstruction is controversial; bypass shunt is usually required and long term follow-up studies are required to establish safety and efficacy.

Cardiac tumours: an observational study.

We studied 38 patients with cardiac tumours. Of these, 30 had primary cardiac tumours while the rest had secondary tumours. The commonest manifestations in patients with primary tumours were exertional breathlessness (23), fever (9), mitral diastolic murmur (15), loud pulmonary component of the second heart sound (16), and mitral systolic murmur (21). Left atrial myxoma was the commonest diagnosis (24) followed by left ventricular leiomyoma (2), right atrial myxoma (2, one with RA and RV both), RV myxoma (1), and left ventricular haemangioma (1). The commonest modes of presentation of secondary cardiac tumours were atrial extrasystoles (5) and pericardial friction rub (4). Histopathological reports revealed bronchogenic carcinoma (4), breast carcinoma (2), seminoma of the testis (1) and lymphoma (1). The unexpectedly low number of secondary cardiac tumours in this series is attributed to the lack of routine autopsy studies in our institute.

Significance of exercise induced increase in diastolic pressure as an indicator of severe coronary artery disease.

A total of 100 patients were studied for the diastolic blood pressure response to treadmill exercise testing. No change in the diastolic pressure or lowering of the pressure was considered normal response. Seventy four patients had normal and 26 patients had abnormal diastolic blood pressure response. Out of these, 40 patients underwent coronary angiography. Fifty five percent of the patients with normal diastolic pressure response had normal coronaries compared to 20% with abnormal response (p < 0.03). Fifteen percent with normal response had triple vessel disease or left main coronary artery disease whereas forty percent with an abnormal response had significant disease (p < 0.03). Exercise induced ST segment depression was almost equal in both groups. Hence we can conclude that abnormal diastolic pressure response to treadmill exercise testing is a fairly good indicator of coronary artery disease irrespective of ST segment changes.