The 5 Types of Hepatitis

Common conditions, Health, Lifestyle

Hepatitis liver

The liver is a vital organ located in the upper right part of your belly under the ribs.

Functions of the liver:

  • Making bile, a yellowish-green liquid that helps with digestion
  • Producing proteins and blood-clotting factors that the body needs
  • Regulating glucose (sugar) in the blood and stores extra sugar
  • Working with the stomach and intestines to digest food
  • Storing vitamins and minerals
  • Removing toxic (poisonous) substances from the blood

“Hepatitis” means inflammation of the liver. Hepatitis is also the name of a family of viral infections that affect the liver.

There are 5 types:

  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis E

The most common types of hepatitis disease are Hepatitis A, B and C. 

Causes of infection and types –

Hepatitis A: This is caused by consuming food or drinking water that is contaminated with faecal matter (human waste). As compared to other infections of hepatitis, hepatitis A usually improves without treatment.

Hepatitis B: It can be transmitted through sexual contact with an infected partner, through infected blood transfusions and dirty needles. Hepatitis B may scar the liver (cirrhosis) and lead to liver cancer.

Hepatitis C: This is the most common form of viral hepatitis. The exact cause is unknown, but it can happen through blood transfusion of infected blood and blood products, contaminated injections and through injection drug use.

Hepatitis D: Hepatitis D occurs in people with hepatitis B, increasing the severity of symptoms associated with hepatitis B.

Hepatitis E: Similar to hepatitis A, hepatitis E happens among people in countries with unhygienic living conditions where contaminated water and food consumption often leads to a spread of infection.

Which hepatitis is dangerous?

  • Types B and C have been reported more among people leading to a chronic (long-term) illness of liver disease. It is the most common cause of liver cirrhosis (liver tissue scarring) and cancer.
  • In addition, there are vaccines to prevent Hepatitis A and B. However, there is no known vaccine for Hepatitis C.

Period of illness with different types of hepatitis

Acute Hepatitis viral infection: This is a short-term illness that occurs within the first 6 months after someone is exposed to the hepatitis virus. Hepatitis A and E may not cause chronic hepatitis but for some with compromised immunity and delayed treatment, it may lead to chronic infection.

Chronic Hepatitis virus infection: Hepatitis viruses B and C can progress from acute to chronic episodes of illness after about 6months. It is long-term as the virus remains in a person’s body and continues to affect liver cells for years to an extent that there can be a complete liver failure.  

Pathophysiology of Hepatitis infection

Acute infection: The course of the virus is not completely understood but once it enters into the body, it multiplies and the infection persists due to weak immune responses which fails to control the viral spread of infection. Symptoms will appear and continue.

Chronic infection is established with the progression of infection. Liver lesions appear due to the immune responses and inflammation of the liver cells. It also triggers fibrogenesis in which the cells of the liver become hard, thickened and fibrous. This leads to scarring of the liver tissue known as cirrhosis. People with cirrhosis are then at high risk of developing end stage liver disease (ESLD) with hepatocellular carcinoma (cancer of the liver cells). 

Chronic hepatitis

Fig 1: Stages of liver infection with Hepatitis C virus(HCV)

Signs and Symptoms with all types of hepatitis

  • Fever due to infection.
  • Fatigue due to loss of appetite, nausea, and vomiting. Also, lead to long-term weight loss.
  • Abdominal pain due to build-up of fluid in the stomach due to inflammation. This occurs when the damaged liver doesn’t produce enough albumin, a substance that regulates the amount of fluid in cells. This may also lead to Pale colored stools, darker urine.
  • Joint pain: Pain and stiffness are early signs of inflammation caused by the body’s autoimmune response to the hepatitis virus.
  • Jaundice: Bilirubin present in the hemoglobin of the red blood cells can build up and cause your skin and the whites of your eyes to turn yellow. 
  • Brain problems: A build-up of toxins in the brain can cause personality changes. Advanced symptoms include abnormal shaking, agitation, disorientation, and slurred speech.
  • Diabetes: Liver is unable to store excess glucose and too much sugar is present in the bloodstream which may lead to insulin resistance or type 2 diabetes.

Who may be at risk of getting Hepatitis?

  • Infants born to infected mothers can get hepatitis B
  • Travelers to regions with high risk of Hepatitis infection most commonly reported in Asia, Africa, South America and the Caribbean.
  • Sexual contact with infected persons that cause viral transmission through body fluids.   
  • Household members, healthcare professionals and caregivers of infected persons through an accidental transmission.
  • Recipients of blood transfusions who may have accidentally received an infected blood.
  • Long-term hemodialysis patients through an accidental infected needle use or blood transmission.

Diagnosis of hepatitis

Blood tests for the antibodies can be helpful in diagnosing both acute and chronic hepatitis. Physical examination of the symptoms along with diagnostic studies such as ultrasound scan of the liver or a liver biopsy is also done to determine the severity of liver damage.

Prevention and Treatment of Hepatitis

Immunization :

  • Hepatitis A immunization of children (1-18 years of age) consists of 2-3 doses of the vaccine. Adults need a booster dose every 6-12 months following the initial dose of vaccine. The vaccine is thought to be effective for 15–20 years or more.
  • Hepatitis B vaccines provide protection against hepatitis B for 15 years and possibly much longer. All newborns and individuals up to 18 years of age and adult should be vaccinated. Three injections over a 6 to 12-month period are provided for full protection.

Safety Measures to Prevent Hepatitis

  • Hygiene: Wash your hands after going to the bathroom and before cooking or eating.
  • Protective sex: This may lower the risk of transmission. It’s always wise to know the history of your sexual partners, especially if they have an infection, you may run the risk of contracting the disease.
  • Drinking clean water: Avoid tap water when traveling to certain countries or regions.
  • Careful handling of drug needles and use of disposable drug needles only.
  • Avoid sharing personal items such as toothbrushes, razors and nail clippers.

Once diagnosed with hepatitis, the treatment will depend on the type and stage of infection. Most adults recover completely from acute hepatitis A and B within six months period. Mild relapses may occur over time during the recovery of the disease. 

Early detection and treatment show excellent recovery from both hepatitis B and C. Further research development continues to provide a vaccine for hepatitis C.

 

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Obesity – Adult vs Children

Common conditions, Food, Health, Lifestyle

Obesity

Obesity is the presence of excessive adipose tissue (fat) mass affecting the health status of any individual to an extent that it may lead to the risk of other serious health conditions. It is one of the most common global health problem replacing the more traditional public health issues.

Obesity in adults vs children

In order to classify an adult as obese, the body mass index (BMI) can be calculated that best classifies an individual according to his height and weight. 

BMI: It is the weight of the individuals body divided by the square of the body height ( expressed as kg/m2). The standard classification of an individual is given in table 1.

BMI good one

Note-BMI is not the best indicator for health as your excessive weight can also be due to healthy bulging muscles rather than fat storage. It does not give information on the fat storage distribution in the body especially in the waist region and cannot be used as a predictor for lifestyle changes and benefits.

Obesity in children  

In infants and children within 5 years of age, the obesity is determined according to the World Health Organization (WHO) “Child growth standards” and the WHO reference values for 5-19 years (body mass index-for-age).

WHO classification (birth to age 5)

  • Obese: Body mass index (BMI) > 3 standard deviations* above the WHO growth standard median*. 
  • Overweight: BMI > 2 standard deviations* above the WHO growth standard median*.

WHO classification (ages 5 to 19)

  • Obese: Body mass index (BMI) > 2 standard deviations* above the WHO growth standard median* (equivalent to BMI 30 kg/m2 at 19 years).
  • Overweight: BMI > 1 standard deviation* above the WHO growth standard median* (equivalent to BMI 25 kg/m2 at 19 years). 
*Growth Standard median: This is the standard of weight given for boys and girls by WHO according to the weight-for-length and weight-for-height of the children at a particular age.
*Standard Deviation: The weight difference of a child when compared to the mean (average) weight of the children belonging in the same age group.

Other classification for childhood obesity

  • Child is overweight: if BMI at or above the 85th percentile* and lower than the 95th percentile for children of the same age and sex.
  • Child is Obese: if BMI is at or above the 95th percentile* for children of the same age and sex.
*Percentile: It is a term used in statistics to give a value of a percentage of a child’s weight compared to the weights of the children of the same age group. For example, a test score that is greater than or equal to 75% of the scores of people who took the test is said to be at the 75th percentile rank.

Measuring Body fat in Adults

Waist Circumference: This method measures excessive fat around the waist and can be used as an additional measure in people who are obese or pre-obese according to the BMI.

For men, a waist circumference no more than 94cm and for women no more than 80cm is considered a safe range. Beyond which, one can develop obesity-related health problems.

Factors that lead to obesity

Genetic factors: The risk of obesity can be more if one or both parents are obese. This relationship of genes and obesity due to the environment and eating habits.

Age: With age, there can be a decrease in the metabolism of the body and loss of muscle mass. If physical inactivity ensues, coupled with bad eating habits, this can easily increase their ability to store fat in the body. Sometimes hormonal changescan also play a role leading to obesity. 

Gender differences: Women tend to gain weight during pregnancy due to hormonal changes.  Hormonal changes including estrogen, progesterone hormones can lead to weight gain. Imbalances in these hormones can also trigger insulin resistance, which in turn, leads to fat storage. In Men, imbalances in testosterone hormone can lead to weight gain. In general, it is observed that women are more at risk of weight gain compared to men also due to lifestyle differences.

Lifestyle:

  • Physical activity: With improvements in modern technology and conveniences, there is an increasing lack of physical activity. 
  • Food habits: Consuming foods with excessive fat, sugar and calorific foods. Increased snacking and overeating can lead to excessive fat storage.
  • Stress and lack of sleep: Both stress and lack of sleep can slow the body’s metabolism. Eating late at night can cause indigestion and leads to fat storage. 
  • Socio-Economic Status: Lack of resources, lack of access to healthy foods, unable to afford healthy foods or improper cooking habits, eating out too often can all lead to obesity.  
  • Side effects of medications: Certain pain medication, corticosteroids, antidepressants, thyroid medications taken by people with thyroid problems and other medicines can slow down metabolism and lead to fat storage. 
  • Known Medical Problem: Arthritis in the lower limb causing pain on weight bearing can reduce physical activity that leads to increasing fat storage.

Diseases such as stroke, kidney disease, Prader-Willi syndrome, Cushing’s syndrome and many others can prevent the person from engaging into physical activities due to pain or muscle/joint problems etc.  

Consequences of Obesity

obesity problems

Metabolic problems: 

The major metabolic risk factors resulting from obesity are

  • An increase in the total cholesterol concentrations especially triacylglycerol concentrations, and high-density lipoprotein (HDL) concentrations.
  • High blood pressure
  • Diabetes: Insulin resistance and glucose intolerance.

All this may lead to Metabolic syndrome that describes a group of risk factors that can increase the risk of developing a heart condition. 

Diabetes: Obesity can lead to deficiencies in sex-specific steroid hormones (estrogen, progestin etc) that causes insulin resistance and a decrease in glucose metabolism. 

Coronary Heart Disease (CHD): Metabolic syndrome and diabetes can lead to atherosclerosis and blocking of the major arteries of the heart leading to a heart condition.

Osteoarthritis: Osteoarthritis (OA) is an inflammatory condition that can be caused by obesity. Excessive weight gain can lead to wear-and-tear of the cartilage and bone leading to inflammatory joints. Other reasons underlying the relationship between obesity and osteoarthritis can be metabolic changes associated with increased fat storage. 

Pulmonary disease: Excessive weight gain in the upper body can increases breathlessness that will lead to CO2 retained in the body and a mismatch in the ventilation and blood flow that further worsens the respiratory system.

Hypertension: The exact cause is unknown, however, due to weight gain there is an increase in resistance to blood flow to and from the extremities. Increases in body mass index (BMI) can put an individual at a higher risk of developing hypertension. 

Gallbladder disease: Obesity is associated with increased secretion of cholesterol in the gallbladder that increases the risk of gallstones particularly cholesterol gallstones.

Hormonal disturbances: Increased obesity in women leads to increased male hormone (testosterone) production leading to hormonal imbalances. Upper body obesity is associated with an increase in testosterone that may be a major cause of problems related to menstruation. Obese men can also get hormonal problems that lead to erectile dysfunction. Childhood obesity can cause early puberty and hormonal problems later in adulthood.

Some forms of cancer:  There is an increased risk of growth of cancer cells in various body tissue among obese people. 

Fatty liver: Nonalcoholic fatty liver disease, a condition in which fat storage is excessive in the liver that can cause inflammation of the liver tissue and scarring(Cirrhosis).

Various psychological problems: There has been increased links of obesity with depression and mood problems possibly due to underlying hormonal problems or other conditions.

Prevention and Treatment 

  • Realistic healthy weight loss goal

Comprehensive lifestyle changes: 

  • Dietary changes: Avoid calorific or sugary foods. Developing meal plans to track what you consume. Seeking advice from a specialist to know what nutrients you are lacking or how to go about the changes. 
  • Increasing physical activity
  • Exercise: 3-4 times per week for 30 minutes each. 
  • Group support: Joining a weight loss group can help psychologically and improve motivational level toward achieving your goals.
  • Relaxation and stress management

Adherence to a weight loss program is important to bring about changes and to prevent health problems due to obesity. For further detailed assessment and treatment, it is best to consult an expert for individualized weight loss programs.

What is Middle East Respiratory Syndrome (MERS)

Common conditions

Passengers wearing masks to prevent contracting Middle East Respiratory Syndrome (MERS) walk past a thermal imaging camera (unseen) at Incheon International Airport in Incheon, South Korea, June 2, 2015. REUTERS/Kim Hong-Ji

What is MERS?

The Middle East respiratory syndrome is a viral life-threatening infection caused by the coronavirus (MERS-CoV).

Signs and Symptoms of MERS

Although uncommon, these symptoms may be present:

  • Fever
  • Cough
  • Breathlessness

More serious symptoms:

  • Chills
  • Diahorrea
  • Nausea/vomiting
  • Coughing out blood

Complications of MERS

  • Pneumonia
  • Kidney failure
  • worsening of pre – existing diseases like diabetes, cancer, heart problems etc.

Source of MERS-CoV 

The exact source is unknown. However, camels and bats are suspected to be the main host of origin for these viruses. Camels are reported to be able to carry these viruses but it cannot be explained how many of the humans got infected without having any direct contact with camels. Bats can also carry and they often feed on fruit that’s harvested by people, so that is another possible route.

What does the virus do to the human body?

One of the most important cells of the human immune system is the macrophages. These macrophages help to eliminate any infections.

MERS-CoV can establish a productive infection in the macrophages. This induces a release of pro-inflammatory cytokines leading to:

  • Severe inflammation
  • Tissue damage

These manifest clinically as severe pneumonia and respiratory failure. The cells of the lungs are infected the most by MERS-CoV.

Severe acute respiratory syndrome (SARS) and MERS

Both SARS and MERS are relatives and have come from the Coronaviruses. They are a large family of viruses that can cause a range of illnesses in humans, from the common cold to the Severe Acute Respiratory illnesses (SARS). Viruses in this family also cause a number of animal diseases. Compared to SARS, MERS-CoV appears to be more severe and have been reported to be the cause of death to more people (40% versus 10%), more quickly and especially more severe in those with pre-existing medical conditions.

MERS is a global threat

Since the discovery of MERS in 2012, it is considered a pandemic threat to the Gulf region. However, MERS-CoV has now reached about 23 countries affecting thousands of people. 

Although MERS have been reported in US, UK, France, Germany and other countries, strict measures have been taken to stop the spread and since then there has been a decline in the numbers infected.

2015 updates on the Countries with travel-associated MERS cases: Algeria, Austria, China, Egypt, France, Germany, Greece, Italy, Malaysia, Netherlands, Philippines, Republic of Korea, Tunisia, Turkey, United Kingdom (UK), and United States of America (USA) 

However, people in South Korea are still facing the problems of MERS and about 2,300-plus people are quarantined and 1,800 schools closed in South Korea due to the fast spreading of this virus.  

Possible reasons why South Korea has more MERS cases

  • As per reports, the first patient who contracted MERS from a travel visit to the middle east when returned to Korea was left undiagnosed for a week. In that time period, many health professionals and other people who came in contact got infected.
  • There was not enough infection control taken. Bad ventilated hospital rooms may have aided the spread of the virus.
  • South Korea has also been quick to report MERS cases to the World Health Organization as compared to other countries.
  • The worst possibility that the virus may have mutated and become more infectious. Although further research needs to be done to know the exact cause as of now the World Health Organization (WHO) reports, “”There is no evidence to suggest sustained human-to-human transmission in communities and no evidence of airborne transmission. However, MERS-CoV is a relatively new disease and information gaps are considerable.”

The Ministry of Health (MOH) in Singapore continues to closely monitor the recent progress on research regarding MERS-CoV infections. As of now, no cases of MERS-CoV have been detected in Singapore. Nonetheless, given today’s globalised travel patterns. Awareness and strict precautionary measures should be undertaken.

Who is at risk of being infected?

  • Travelers: People who have come in close contact with infected people while travelling to high-risk countries.
  • Consumption of Camel products.
  • Compromised immune system: People who have lung, heart or other conditions or diseases have lower immunity and are more susceptible to the viral infection.
  • Contact with infected person such as health care professionals in hospitals. Also, people who take care of animals like bats and camels may be at increased risk. 

How does MERS-CoV spread? 

The virus can spread between people in close contact. It can spread through the air as the infected person sneezes and releases viral droplet in the air which could spread across to other individuals in close contact. 

The average incubation period has been reported to be 5 days but there are cases that occurred up to 14 days after exposure. Incubation period refers to the amount of time when a person is first exposed to the virus and when the symptoms starts to occur.

How is MERS diagnosed?

There are two main ways to determine if an infection is with MERS-CoV.

  •  Polymerase chain reaction (PCR) analysis: PCR tests are done with respiratory samples and can quickly indicate if a person has an active infection with MERS-CoV.
  • Serology testing: blood samples designed to look for antibodies to MERS-CoV that would indicate a person had previously been infected with the virus hence developed an immune response.

Other tests

  • X-ray to determine the extent of the damage: All patients with MERS have an abnormal chest X-ray. Pneumonia is commonly seen as shown in Fig 1.  The black portion shows the normal air-filled spaces in the lungs and the white portion on the left lung is called infiltrates (filling of air spaces with infectious fluid) that identifies the presence of pneumonia infection. 
image016 (1)

Fig 1: Pneumonia in the Right lung

How to prevent and treat MERS?

There is no known vaccine for MERS and no known medications that have been proved to be effective for the treatment of coronavirus infections. Clinical research is still working on establishing an effective treatment.

Infection prevention and control measures: Especially in healthcare settings, this is important to prevent the possible spread of MERS-CoV.

Early identification of people with MERS-CoV is difficult as like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, standard precautions should be taken with all patients, regardless of diagnosis.

General precautionary measures

  • When in contact with a person with any symptoms of acute respiratory infection, contact precautions and eye protection should be taken. As the infection is airborne, it can spread through the mucosal lining of the eyes and nose. 
  • Even touching contaminated objects or surfaces and then touching the eyes, nose, or mouth can lead to the spread of the infection. 
  • General hygiene measures – regular hand washing before and after touching animals and avoiding contact with sick animals.
  • Food hygiene practices should be observed. People should avoid camel food products.

Until research reveals more about MERS-CoV, people with diabetes, renal failure, chronic lung disease and people with compromised immunity are considered to be at high risk from MERS‐CoV infection. Therefore, these people should avoid close contact with animals, particularly camels when visiting farms, markets or barn areas where the virus is known to be potentially circulating.

The Controversy about Monosodium Glutamate (MSG).

Common conditions, Food, Health, Lifestyle

CRS

In the food industry, great interest has been garnered over the use of a particular ingredient which has caused great controversy overtime. That ingredient is Monosodium Glutamate (MSG). It’s often used as a flavour enhancer. Although additives can improve the taste of many foods, it does carry a threat of causing allergies, food intolerance and even certain conditions among some individuals. 

What exactly is MSG?

MSG is a crystallised water-soluble kind of sodium salt made up of the amino acid “glutamate”.

Glutamate is present in nature both in its free form and usually bound to peptides and proteins. The free form is used as additive and is responsible for the flavour enhancing properties. The bound form does not have any effect on taste and is considered an excitatory neurotransmitter (the ones that keep you alert and awake) as they mediate many signals in the brain and is involved in normal brain function such as cognition, memory and learning. 

Commercially, MSG is made by fermenting molasses, sugarcane, corn sugar or starch. MSG can also be obtained from natural protein-rich foods such as seaweeds. 

How does MSG work?

There are glutamate receptors present in many parts of our body like the brain, tongue and other peripheral tissues.  The MSG used in food stimulates the glutamate receptors of the tongue to give a “meat-like” or “umami” taste to foods. 

MSG – Chinese Restaurant Syndrome (CRS)

MSG consumption has been linked to the term “chinese restaurant syndrome” since 1968. This syndrome is caused due to body’s intolerance to MSG. Although the use of MSG in chinese food is well known, other cuisines, processed foods and many fast foods also contain it. 

It is still considered as a common type of food intolerance that may possibly affect many individuals.  

Who can be more susceptible to MSG Symptom complex?

  • People with Respiratory problems like Asthma.
  • People with known immunity problems with histamine that causes allergies to additives.
  • People with intestinal problems like Coeliac disease.
  • People with a sensitive stomach to additives.

Signs and Symptoms of CRS

The type of allergic reaction, severity and frequency of symptoms can vary from person to person. Sometimes multiple symptoms can occur at the same time.

  • Neurological system:  anxiety or panic attacks, blurred vision, depression, dizziness, excessive sweating, fatigue, hyperactivity, irritable, poor concentration, sleep disturbance, mild to severe headaches, migraines, tiredness and leg cramps, numbness of the upper body, head and neck.
  • Skin problems: eczema, hives (urticaria), tissue swelling, tongue/ throat swelling, atopic dermatitis, facial flushing and burning, and angioedema (quick swelling of tissue under the skin).
  • Gut related problems: bloating(gas trouble), burning mouth or tongue, constipation, diarrhoea, indigestion, mouth ulcers, nausea,  vomiting, abdominal pain, cramping and irritable bowel syndrome.
  •  Respiratory symptoms: wheeze, cough, blocked nose and sinuses, hay fever, sneezing, rhinitis (inflammation of mucosal membrane inside the nose), unstable asthma, and laryngeal oedema.

When should you seek medical care?

Mild symptoms usually subside without treatment, however if symptoms are severe such as excessive swelling of the throat and tongue, difficulty in breathing and raised heart rate. It is best to immediately seek medical care to prevent the complication of allergic shock which is also known as “Anaphylaxis”. It is a potentially life-threatening allergic reaction with excessively severe symptoms associated with the MSG intolerance.

Diagnosis of MSG intolerance?

  • Medical evaluation (clinical assessment) can determine if the symptoms are not due to some other identifiable cause or disease process.
  • Heart rate and ECG-Electrocardiogram may be recorded to check the normal heart rhythm.  
  • Respiratory status will be checked for bronchospasm (narrowing of the airways).
  • Skin prick tests (or RAST) are used as a standard way of detecting allergen-specific IgE (a type of antibody produced in the body).

Prevention and treatment of MSG intolerance

Drinking water: Water can help flush out any allergens from the body especially MSG. It can reduce the impact and delay the occurrence of the allergic reaction. 

Elimination Diet: You can be put on a diet that excludes natural salicylates, amines and glutamate, as well as additives such as preservatives, colourings and MSG. This is to see if your symptoms improve with time.

Medication: Medical care can involve the use of prescribed medications that can help reduce the symptoms of allergic reaction.

Although, a reasonable amounts of such foods can be eaten among mild symptomatic individuals. It is best to avoid it as much as possible to prevent further complications.   

Varicose and Spider Veins – What are they and How to avoid them.

anatomy, Common conditions, Exercise, Health

main pic veins

What are Varicose and Spider veins?

Varicose veins are abnormal, dilated blood vessels (veins) caused by a weakening in the vessel wall. They may appear as swollen, twisted clusters of blue or purple veins.

Varicose veins are sometimes surrounded by thin, red capillaries also known as spider veins.

(group of tiny blood vessels located close to the surface of the skin, also called telangiectasias) – Refer Fig 1.

varicose veins
Fig 1: Varicose vs Spider veins

Role of veins and formation of abnormal veins

Veins carry blood back to the heart and have one-way valves that prevent the blood from back-flowing. The calf muscles act as a pump by which the blood is pumped back from the legs towards the heart as shown in Fig 2.

Deep Leg Veins

Fig 2: Normal blood flow through Veins, Calf muscle pump

If those valves of the veins become weak from extended periods of increased pressure and swelling, the blood can back up and collect within the veins. This causes the vein walls to weaken and bulge with blood, causing the veins to appear swollen and twisted as shown in Fig 3.

deformed valves

Fig 3: Normal vs Abnormal blood flow

Who can get it and where does it happen?

Varicose veins and spider veins can occur both in men and women. However, women are known to be affected more than men due to their hormonal predisposition and changes during pregnancy that affect the veins. 

These abnormal veins can develop anywhere, but most often appear on the legs and in the pelvic area because as compared with other veins in the body. This is because, lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting at the same time. This pressure can be stronger than the one-way valves in the veins.

Most varicose veins are seen on the surface of the skin as the superficial veins get swollen with blood collected in it that get raised on the surface and at times above the surface of the skin.  

Signs and Symptoms

Some may not have any symptoms but may be concerned about the appearance of the veins. Symptoms usually worsen after prolonged standing or sitting as the blood pools or collects in the veins of the lower limbs. 

Print

Fig 4: Swelling, Skin changes and Ulcers due to varicose veins

If symptoms occur, they may include:

  • Tiredness, burning, throbbing, tingling or heaviness in the legs
  • Itching around the vein
  • Swollen legs (Refer Fig 4)
  • Muscle cramps, soreness or aching in the legs
  • Brown discoloration of the skin, especially around the ankles (Refer Fig 4)
  • Leg ulcers (Refer fig 4)
  • Rarely varicose veins can form a painful blood clot, referred to as superficial thrombophlebitis (inflammation of a vein).

Risk factors and causes of abnormal veins

Varicose veins are related to increased pressure in the leg veins or defective valves in the veins.

They can happen due to reasons:

  • Idiopathic: The exact cause of this problem is unknown.
  • Heredity: A family history of varicose veins can put a person at risk of developing abnormal veins.
  • Advancing age: With aging veins can lose elasticity causing them to stretch. The valves in your veins may become weak, allowing blood that should be moving toward your heart to back-flow.
  • Prolonged standing or sitting.
  • Being overweight puts extra pressure on your veins, which means damage to the valves, making them more prone to swell.
  • Pregnancy: Pregnancy increases the volume of blood in your body but decreases the flow of blood from your legs to your pelvis. This circulatory change is designed to support the growing foetus but it can produce an unfortunate side effect — enlarged veins in your legs.
  • Hormonal influences during pregnancy, postmenopausal hormonal replacement therapy and use of birth control pills can cause excessive swelling in the lower limbs that hampers blood flow through veins. 
  • Wearing tight clothes can put pressure on the veins which can cause abnormal blood flow.
  • Injury to the veins due to trauma or accidents.
  • Other health conditions that cause increased pressure in the abdomen including liver disease, fluid in the abdomen, previous groin surgery or heart failure.

How is Varicose and Spider veins diagnosed?

A physical examination of the body especially the legs while the person is standing is done. A Doppler ultrasound scan can also check the blood flow in the veins near the skin’s surface and the deep veins. 

When to seek medical care?

  • Walking or standing becomes painful.
  • Soreness develops on or near a varicose vein
  • Your feet or ankles swell up very frequently.

If immediate care is not taken, symptoms may worsen. Complications may develop if there is an underlying disease in the deep veins or in the perforating veins which connect the deep and superficial veins.

  • Chronic venous insufficiency: Untreated venous problems may progress to a chronic condition of abnormal blood flow through the veins.
  • Venous stasis ulcers that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer (open sore) may form.
  • Fungal and bacterial infections may occur as the result of skin problems caused by the fluid buildup (edema) in the leg. These infections also increase the risk of tissue infection (cellulitis).
  • Thrombophlebitis: Inflammation of the vein due to blood clot formation.
  • Venous hemorrhage: Bleeding through the veins due to micro-tears and ruptures.

How to prevent varicose veins and its complications?

Lifestyle modifications:

  • Losing weight if you are overweight
  • Exercising regularly (especially walking)
  • Avoiding prolonged periods of sitting or standing
  • Avoid wearing tight-fitting undergarments and clothing that constricts the waist, groin or legs.
  • Avoid crossing your legs while seated.
  • Elevating your legs while sitting and sleeping will help.
  • When you need to stand for long periods, take frequent breaks – sit down and elevate your feet.
  • Do ankle pump exercises as shown in Fig 5.

ankle pumps

If you still develop varicose or spider veins, it is best to seek medical attention to know more in details on exercises and lifestyle changes that can be personalized to your needs.  

Why is Deep Vein Thrombosis Dangerous?

Common conditions, Exercise, Health, Lifestyle

DVT What is thrombosis?

Thrombosis is a process by which there is clotting of the blood in a part of the circulatory system. This causes a partial or total obstruction thus preventing blood from flowing normally through the circulatory system. This clot is known as a thrombus. 

What is Deep Vein Thrombosis(DVT)? 

A blood clot (thrombus) in the deep venous system is known as DVT. These clots are formed in the deep veins which are a part of the circulatory system that helps bring deoxygenated blood back to the heart. These veins have one-way valves that function to transport blood from various parts of the body to the heart as shown in Fig 1.

veins of our body

Fig 1: Deep veins of the body

Which body part can be affected with DVT?

There is a greater risk of developing DVT in your lower limbs than upper body as the deep lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting on them at the same time. In addition, if there are other factors that increases the pressure exerted on the valves in the deep lower limb veins, there are more chances of blood collecting within the veins thus making the lower limbs deep veins more susceptible to DVT.

Why is DVT dangerous?

There is a risk of a partial or complete detachment of this thrombus formed in the deep veins. This allows the thrombus to move with the blood flow and block other blood vessels. This process is called as venous thromboembolism.

pulmonary embolism

Fig 1: Thromboembolism

As shown in Fig 1, the thrombus blocks the blood vessel and cuts off the circulation to a particular body part or organ. This will lead to a lack of oxygen to the tissue (ischemia) and a loss of tissue function. The clot can also reach other blood vessels that supply the vital organs of the body, putting the body at a dangerous risk of stroke, lung, heart problems and post-thrombotic syndrome (PTS).

Post-thrombotic syndrome is a chronic(long-term) problem that occurs with DVT and involves chronic leg pain, swelling, redness, and ulcers (sores).

How does a thrombus form in the deep veins?

Blood clotting is the transformation of liquid blood into a semi-solid gel. The blood has a protein called fibrin. Fibrin is usually in its inactive state but when tissues or blood vessels are damaged, it becomes active. This process is called coagulation. The main reason of thrombus formation can be explained by the Virchow’s triad as shown in fig 2.

cause of thrombus

Fig 2: Main causes of thrombus formation

Conditions of prolonged bed rest or immobility which could be lifestyle-related or due to other reasons may cause stasis of blood within the veins that may lead to clot formation. Also, if there is an imbalance of the coagulation and anti-coagulation factors in the blood which may be caused by an injury or acute/chronic inflammation to the blood vessel walls may cause blood clot formation.

Who is at risk of developing DVT?

  • Anyone with vein trauma due to broken hip or leg fractures during accidents.
  • Long periods of air travel coupled with lack of movement in sitting position can cause excessive swelling in the legs and stagnation of blood flow leading to clot formation.
  • Bed bound individuals post-surgery, muscular paralysis from a spinal cord injury, pregnancy or having recently given birth, especially by C-section, causing swelling and lack of calf muscle strength that impair blood circulation in the legs.
  • People with inherited blood clotting disorder.
  • People who have cancer as tumors shed particles that contain procoagulant activity.
  • Smoking affects blood circulation and stiffens the blood vessel wall making a smoker at higher risk of DVT.
  • Side-effects with the use of hormone therapy, including that used for postmenopausal symptoms among women.
  • Individuals with varicose veins, which are swollen, twisted and painful may develop clots.
  • People with a history of heart attack, stroke or congestive heart failure have high levels of cholesterol in the blood that lead to inflammation and possibly clot formation.

Signs and Symptoms of DVT

  • Pain, swelling and tenderness in one of your legs (usually your calf)
  • Affected area can be very painful and heavy.
  • Warm skin in the area of the clot.
  • Redness of the skin, particularly at the back of your leg below the knee.

How is DVT diagnosed?

A physical examination may not be enough as there may be individuals with no possible signs of DVT. Diagnostic tests will be necessary to confirm the condition.

  • Doppler ultrasound scan:  A clot may be visible in the image. Sometimes a series of ultrasounds are done over several days to determine whether a blood clot is growing or to detect any formation or movement of a clot.
  • Blood test: An elevated level of a clot-dissolving substance called D dimer will be found in the blood.
  • Venography. A dye (contrast agent) is injected into a large vein in your foot or ankle. An X-ray procedure is then undertaken that creates an image of the veins in your legs and feet, to look for clots. 
  • CT or MRI scans. Both computerized tomography (CT) scan and magnetic resonance imaging (MRI) can provide visual images of your veins and may detect any clot formed. 

When to seek medical care?

  • If you get swelling, redness, and pain in your leg, it may indicate a blood clot and immediate medical attention should be given. Sometimes there may not be any signs or symptoms or these symptoms could be due to other inflammatory condition or infection, therefore, it is difficult to make the diagnosis without seeking medical advice.
  • If there is associated pain in the chest or breathlessness further concern exists that you may be at risk of a pulmonary embolus. This could be a potential danger hence if you are at risk its best to discuss with your doctor about taking medications for preventing clot formation.

How to prevent DVT?

  • Compression stockings for bed bound individuals.
  • Early ambulation Post-surgery – getting the individual out of bed walking to allow good circulation of blood. If not possible, use a continuous passive motion (CPM).
  • Low dose of anti-coagulants can also be prescribed by the doctor.
  • During long flights, it is recommended to move frequently and/or use compression stockings.
  • Ankle exercises can help pump the blood from the legs upwards to the heart.
  • Lifestyle modifications –  smoking cessation and increased exercise.

If in doubt or experiencing any of the symptoms, always seek medical advice immediately. When detected early, it’s much easier to deal with.

What is Torticollis – Congenital and Acquired

Common conditions, Health, Injury, Pain

MAIN WRY NECK

What is Torticollis?

Torticollis is derived from the Latin word tortus, meaning “twisted” and collum, meaning “neck”.  It is an abnormality, where the muscles in the neck that control the position of the head are affected causing the head to tilt and/or rotate to one side or be pulled forward or backward. This condition is also known as “Wry neck” or “Cervical dystonia”.

What happens in torticollis?

Acute injury to the soft tissue structures of the neck is the most common presentation that causes inflammation, spasm and shortening of the muscles of the neck. Characteristic head tilt with the ear moved toward the shoulder happens from an increased tone in the neck muscles. 

Most commonly, the trauma is to one of the neck muscles called sternocleidomastoid (SCM). This muscle is present in front of the neck on each side and runs diagonally from the collar (clavicle) and breastbone to the mastoid process and the base of the skull bone as shown in Fig 1.

sternocleidomastoid FRONT VIEW

In torticollis, there is shortening or excessive contraction of the SCM on one side of the neck. The head is typically tilted sideways towards the affected SCM and rotated with the chin facing to the opposite side as shown in Fig 2. 

CT

Pathophysiology of torticollis

As shown in Fig 2, Torticollis can be of two types.

  • Congenital
  • Acquired

Congenital Torticollis

“Congenital” means a physical abnormality present from birth. Congenital torticollis is an abnormal positioning of the neck caused due to the damage of the nerves or the blood supply of the neck. This occurs due to various reasons such as, 

  • Intrauterine (inside uterus) malposition of the baby 
  • Trauma while undergoing breech or difficult forceps delivery, fracture to the collar bone (clavicle) of the child during birth. 
  • Genetic birth defects: For example, webbing of the neck deformity seen in various syndromes, including Turner’s, Klippel-Feil, or Escobar-Syndrome. Brachial cleft cysts, vertebral bone problems, odontoid hyperplasia, spina bifida, hypertrophy or absence of neck muscles, and Arnold-Chiari syndrome.

Acquired Torticollis

This condition clinically presents because of other problems that affect the musculoskeletal structures of the neck. It typically occurs in the first 4 to 6 months of childhood or later affecting both children and adults. 

Reasons for Acquired Torticollis

  • Idiopathic or Unknown cause: Also classified as “Dystonia” which is a disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures. It is unclear but believed to occur due to lesions in an area of the brain (thalamic lesion). 
  • Postural problem: The problem with neck muscles can arise from a prolonged incorrect posture of the neck. It may appear overnight when, for example, a person has slept with his/her neck in an awkward position. Other activities like holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
  • Vision problem: Problem with vision in one eye can cause the individual to tilt his or her head to see better affecting the neck muscles on one side.
  • Trauma: Sudden accidental bend or twisting of the neck too far. Whiplash injury of the neck.
  • Infection: Inflection of upper respiratory, ear, or sinus lead to inflammation of the cervical lymph nodes that can irritate the nerves supplying the neck muscles causing torticollis. It can also damage the soft tissues and cause improper alignment of the neck bones.
  • Arthritis of the neck joints: Inflammatory joint conditions like cervical spondylitis, intervertebral disc problems of the neck can also cause torticollis.
  • Side effects of certain medications: Inflammation caused by many antipsychotic and antiemetic medications can cause Spasm or dystonia of the neck muscles.  
  • Neurogenic abnormalities: Spinal cord tumor or progressive spinal cord diseases can cause problems in the neck region. 

Signs and Symptoms of Torticollis

  • Inability to move the neck with limited range of motion
  • Chin tilted to one side
  • Headaches
  • Head tremor
  • Neck muscle spasm and pain
  • One shoulder is higher than the other
  • Spasms in other areas of their head such as their eyelids, face, or jaw, as well as in their hands
  • Stiffness of the neck muscles
  • Swelling of the neck muscles (possibly present at birth)
  • Other neurological signs: Difficulty in speaking, drooling, respiratory problems, swallowing difficulty (trouble initiating), tingling sensation in the neck, upper back and arm due to nerve problems, depression, self-consciousness.

When to seek medical care?

Congenital torticollis can be easily identified after childbirth and determine  the severity of the condition related to its neurological involvement. If a child or an adult suffers from neck problems, it is best advised to seek treatment immediately to prevent worsening of the pain and to prevent the development of torticollis.  

How is torticollis diagnosed?

A thorough assessment of the condition related to the history of the individual will be taken. Any injuries to the neck can be detected by certain diagnostic tests like an X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI).  However, it’s unlikely that the exact cause of the muscle spasm can be isolated.

In children and infants, experts can detect neck muscle damage that may cause torticollis through routine physical examination. Newborns will be assessed for the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth through visual observations.

How can torticollis be treated?

Treatment should begin immediately for infants with torticollis. At this stage, it is most successful in reversing the deformities caused by torticollis. For example, as the child grows with torticollis, the face on the tilted side may become flattened. This flattening can be reversed while the bones are young and soft but after one year of age it is most likely that the bones get fused and the deformity may become permanent. 

Other problems with delayed treatment 

  • Difficulty learning to walk and frequent falls seen because the head tilt causes unequal weight bearing and loss of balance.
  • Open mouth posture with the tongue pulled to one side or the other.
  • Suck/swallow may be affected leading to feeding issues.
  • A permanent trunk and facial asymmetry can occur.

 Chances of torticollis relapse

Most cases of muscular torticollis have good outcomes, however, there is a chance of relapse with both non-surgical and surgical treatments. Sometimes even if the recovery is spontaneous with continued treatment, there may still be a possible head tilt of small degree.

The outcome will also differ depending on the severity of the injury to the soft tissue and joint structures of the neck.

General goals for treatment,

  • Reducing pain, spasm and muscle strains of the neck.
  • Improving mobility and flexibility of the soft tissue structures affected.
  • Reducing stiffness in the neck and mobilizing the joints of the neck.
  • Postural correction and awareness by changing or selecting positions that will be beneficial for the neck.
  • Functional exercises to the neck muscles to restore stability, strength, and mobility of the neck.
  • Reassurance and education to prevent emotional stress, providing support to cope with social embarrassment.

There is no sure way to prevent wryneck and congenital torticollis; however, utmost care should be taken to avoid trauma to the child as much as possible during delivery. 

Restless Legs Syndrome

Common conditions, Exercise, Foot, Health, Lifestyle

restless leg syndrome

What is restless legs syndrome?

Restless legs syndrome (RLS) is a neurological disorder that is characterized by an uncomfortable sensation in the legs and rarely the arms. This leads to an overwhelming urge to move them continuously.

These movements may,

  • happen to partially or totally relieve discomfort.
  • begin or worsen during periods of rest such as lying or sitting
  • worsen during sleep, causes time to time movements also known as “periodic leg movements”.

It has also been suggested that RLS would be called “Willis-Ekbom disease”, as an homage to the two pioneers Thomas Willis and Karl-Axel Ekbom who first reported this condition. 

What causes RLS?

  • Unknown cause
  • Genetic cause

RLS symptoms are related to hyperexcitability of the central nervous system- brain and spinal cord due to a possible deficiency of a chemical called dopamine. Dopamine plays a role in controlling muscle movement and may be responsible for the involuntary leg movements associated with RLS.

  • Disorder of the peripheral nervous system

The peripheral nervous system involves the nerves that carry signals from different parts of the body to the brain. The most likely possibility is the presence of hypoxia (lack of oxygen) caused by changes in blood flow or metabolism in the lower limbs that irritates the sensory nerves of the legs causing restlessness. 

  • Iron-deficiency anaemia – low levels of iron in the blood can lead to a drop in dopamine, triggering restless legs syndrome
  • Chronic (long-term) health conditions – such as chronic kidney disease, diabetes, Parkinson’s disease, rheumatoid arthritis, an underactive thyroid gland or fibromyalgia.
  • Radiculopathies: Radiculopathies are problems with the nerves and occur due to nerve compression at the spine caused by disc herniation and protrusion and/or disc degeneration. It is most commonly seen in the lower back regions (Lumbar spine). Nerve compression could cause referred pain and tingling sensations along the back of the leg to the feet that may be a secondary cause for RLS. 
  • Pregnancy – particularly from week 27 until birth; in most cases, the symptoms disappear within four weeks of giving birth
  • Side effects of certain medication: Antidepressants, Antipsychotic medicine, Lithium (used in the treatment of bipolar disorder), Calcium channel blockers (used in the treatment of high blood pressure), Antihistamines, Metoclopramide (used to relieve nausea). 
  • Lifestyle problems: Excessive smoking, caffeine/ alcohol, obesity, stress and lack of exercise.

Who can be affected with RLS?

  • Both the genders are affected but women are twice as likely to develop RLS than men which is still unknown and is suggested to be related to genetics, body functions or emotional differences. 
  • People of all ages can be affected but more commonly seen among middle-aged people secondary to other health conditions.

What are the signs and symptoms of RLS?

Signs and symptoms may vary from day to day, in severity and frequency from person to person during rest and most often during sleep. 

  • Abnormal sensations (Paresthesias)- pulling, creeping etc.
  • Unpleasant abnormal sensations (Dysesthesias)- the sensations range in severity from uncomfortable to irritating to painful example, tingling, burning, aching or like electric shocks.
  • Periodic leg movements during sleep
  • Typical movements like pacing and walking, jiggling the legs, stretching and bending, tossing and turning, rubbing the legs.
  • Inability to sleep leading to sleep disorders like insomnia (lack of sleep) due to increased urge to move or sudden waking up from sleep due to periodic leg movements.
  • Hyperactivity may be seen among children with RLS.
  • Fatigue/tiredness, lack of concentration, problems with cognitive function (related to thinking, attention and decision making) due to lack of sleep and excessive movements in the leg most often felt throughout the day.

How is RLS diagnosed?

There are no diagnostic tests that can diagnose RLS.

A thorough clinical assessment of the patient is necessary to be able to diagnose this condition. 

  • Clinical history: The history of the patient about signs and symptoms associated with RLS will be important for the diagnosis. The frequency, duration, and intensity of symptoms the aggravating and relieving factors as well as their tendency to occur during day and night time will be noted.
  • Family and Medical History: Family history and problems of other health conditions and the use of medications will be noted that may be the suggestive cause for RLS.
  • Neurological and physical examination: Examination of other underlying conditions related to muscle or nerve problems. 
  • Blood tests: blood test can be done to identify iron and vitamin deficiencies as well as other medical disorders associated with RLS.  
  • Sleep studies such as polysomnography (a test that records the individual’s brain waves, heartbeat, breathing, and leg movements during an entire night of sleep) may identify the presence of periodic leg movements and other problems of sleep.
  • RLS in children: This may be difficult since it may be hard for a child to describe any uncomfortable sensations in the leg and the urge for leg movements, when and how often the symptoms occur, and how long they last.
  • Misdiagnosis: RLS may be often misdiagnosed as “growing pains” or “Attention Deficit Hyperactivity disorder” (ADHD) in children and may be mistaken to be an onset of another neurological disease, such as Parkinson’s disease in adults.

How can this condition be treated?

  • Most symptoms can be treated by therapeutic treatments that improve the blood circulation of the legs, muscle flexibility and allow the nerves of the legs to relax. This can help diminish the uncomfortable sensations caused by restless legs syndrome.
  • Identification and treatment of other health problems are important to reduce the symptoms of RLS.  
  • Intake of diet rich in iron and vitamins will be beneficial.
  • Reducing smoking and alcohol consumption.
  • Stress management will help reduce symptoms and improve sleep.

Severe problems with RLS can be also be treated along with prescribed medications that improve the dopamine levels in the body. However, RLS may generally be a lifelong condition.There may be periods of no symptoms but may eventually reappear sooner or later. Adhering to the treatment methods can help reduce the symptoms at all times. 

Common Injuries of the Achilles Tendon

Ankle, Common conditions, Exercise, Foot, Injury, Lifestyle, Pain

Achilles tendon injury

The thickest and the strongest tendon in our body is the tendon of the calf muscles of the leg also known as the “Achilles tendon”. 

achilles Tendon main

Fig 1: Calf muscles and Achilles tendon

As shown in Fig 1, the calf muscles of the leg include the gastrocnemius and the soleus muscles that tapers and merges with a tough connective tissue of the Achilles’ tendon. The Achilles tendon then inserts into the heel bone (calcaneus).  Functions of the Achilles Tendon

  • Downward Movement of the foot: When the calf muscles contracts and pulls the Achilles tendon it causes the foot to push downward. This contraction enables: gait, standing on the toes, running, and jumping.
  • Bending the knee: The gastrocnemius muscle helps in bending the knee (flexion) during walking and running.
  • Transferring body weight: With each step of walking each of the Achilles tendon help to distribute the person’s body weight. Depending upon the speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subjected to approximately 3-12 times a person’s body weight.
  • Ankle stability: Along with the other muscles of the leg the Achilles tendon contributes to the stability of the ankle joint.

What surrounds the Achilles tendon? The Achilles tendon is protected by the Achilles tendon sheath and bursae. The sheath is the covering of the tendon that protects the tendon from friction and allows smooth movements. Similarly, the bursae around the Achilles is a thin fluid-filled sac that help to reduce friction between tendon and other tissue areas of the heel.

achilles Bursas

Fig 2: Bursae around the Achilles tendon

As shown in Fig 2, there are two bursae present at the heel. One of the bursae is present in between the surface of the tendon and the surface of the calcaneus at the distal attachment of the Achilles tendon. It is called the “retrocalcaneal bursa”. The other bursa is present between the calcaneum and the skin and is called as the “subcutaneous calcaneal bursa”. 

Brief History on Achilles tendon injuries

Because of the Greek Achilles legend, the Achilles heel is known as a vulnerable part for injury. Hippocrates described that “this tendon if bruised or cut causes the most acute fevers, induces choking, deranges the mind and at length brings death”. It was first reported that a ruptured tendon was to be wrapped with bandages dipped in wine and spices. Since then the cause and treatment of Achilles tendon injuries have brought growing interests among many researchers. 

What causes an Achilles tendon injury?

  • Overuse injuries

This is mostly sports related and is due to overuse of the calf muscles causing an injury to the Achilles tendon. Overdoing or rapid action of the calf muscles or resuming too quickly after a layoff can stress the Achilles tendon. For example, while running or walking faster, up and down on steeper hills or stairs  more powerful movements such as lunges, jumps, or push off.

  • Misalignment and muscle imbalances

Short or tight Achilles tendons or calf muscles, unequal leg length, over or under arched foot, disproportionally weak calf muscles.

  • Improper Footwear 
  • Side effects of certain medications  

Medications (Quinolone / Fluoroquinolone and Cortisone) can weaken the Achilles tendon and this may lead to an injury. Cortisone shots in or near the Achilles tendon may reduce pain in the Achilles tendon, but the weakness in the tendons persists which can an injury during activities.

  • Accidental trauma
  • Inflammatory conditions

Achilles injury may occur in relation to inflammatory illnesses, such as ankylosing spondylitis, reactive arthritis, gout or rheumatoid arthritis.

  • Genetic 

Individuals with a genetic predisposition like hypermobile people are reported to be more at risk of developing Achilles tendon problems. This is because they have excessive laxity in  ankle joints that lead to the wear and tear of the Achilles tendon. 

Achilles tendon injuries

achilles tendon injury locations

Fig 3. Locations of injury

As shown in Fig 3, different types of Injuries to the tendon can occur along different locations of the tendon. 

Musculotendinous junction: This explains the junction between the calf muscle and the Achilles tendon.

Mid portion of the tendon: This explains an injury midway between the top and bottom of the Achilles tendon.

Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

Non-insertional Achilles tendon injury means an injury to any part of the Achilles tendon except at the Achilles tendon – heel bone connection.

Types of Achilles injuries

The spectrum of Achilles injuries ranges from an acute inflammatory irritation to severe cases of rupture of the tendon as shown in Fig 4. The types of condition may co-exist depending on the severity of the injury.

Achilles Tendon course of injury

Fig 4: Types of Achilles Tendon Injuries

Tendonitis and tenosynovitis

Achilles tendonitis is an acute inflammation of the Achilles tendon as shown in Fig 5. Tenosynovitis is an inflammatory condition of the Achilles tendon sheath, rather than an inflammation in the Achilles tendon itself.

Tendonitis insertion

Fig 5: Achilles Tendonitis

Achilles Tendinosis (Tendinopathy): This is the degeneration and micro tears of the Achilles tendon that occurs over time due to overuse of an already inflamed and weak tendon (Refer Fig 6).

Both Achilles tendonitis and tenosynovitis can occur in parallel with, or lead to Achilles tendinosis.

Print

Fig 6: Tendinosis of Achilles tendon

Tendon Ruptures (Partial or complete tendon tear) Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. It occurs rapidly while performing activity like running or standing on the toes, which generates intense force on the tendon, leading to partial or complete rupture as shown in Fig 7.

Rupture complete

Fig 7: Complete and partial tear of the Achilles tendon

What can happen if you have an Achilles tendon injury?

  • Pain and tenderness along the Achilles tendon and at the back of the heel that worsens with activity.
  • Thickening of the tendon
  • Bone spur formation at the insert of the tendon
  • Bruising and Swelling around the tendon area.
  • Fibrosis and scarring may be seen in Achilles Tenosynovitis and tendinosis.
  • Restriction of Achilles tendon’s motion within the Achilles tendon sheath.
  • Bursitis: Inflammation of the bursas around the Achilles tendons.
  • Snapping or popping noise can indicate a tendon rupture.
  • Difficulty in moving the foot or pointing your toes (in complete tears of the tendon)
  • A limp may be seen on weight bearing immediately after an Achilles tendon rupture
  • Ankle instability
  • Nerve or blood vessel damage: Signs include numbness, tingling, pins-and-needles sensation in your foot and bruised skin.

How is an Achilles tendon injury diagnosed? An initial examination of the ankle can help differentiate a tendon rupture from other types of injury. When an Achilles tendon rupture occurs, it will not be possible for the individual to stand on toes as shown in Fig 8.

achilles tendon rupture and normal

Fig 8: Achilles tendon rupture of the Left heel

 An MRI or X-ray investigation can also be taken to further confirm the severity of the injury and differentiate the type of injury to the tendon. For example, an MRI scan of a ruptured Achilles tendon is shown in Fig 9.

Complete tear MRI

Fig 9: Achilles tendon rupture

When to seek expert care?

If you felt a sharp pain like a direct hit to the Achilles tendon or if you heard a distinct snap at your Achilles tendon, it calls for a medical emergency. If you have just begun with pain in the back of heels with swelling or discomfort in the Achilles tendon, it would be wise to seek expert assessment and treatment care. What may seem like a mild inflammation may lead to degeneration and rupture. Thus, an initial treatment for tendonitis will not only reduce problems of the tendon but will restore its strength and function which is important to prevent worsening and recurrence of the condition.  

Alcohol Flush Reaction – Why does it happen?

Common conditions, Food, Lifestyle

drinks

Many people experience a prompt reddening on their face after few drinks of alcohol. It is called “Alcohol flush reaction” and is also known as “Asian flush syndrome” due to its greater prevalence among Asians. The reaction is often considered to be a sign of natural body protection mechanism from excessive drinking. What might seem like an unexpected natural reaction is, in fact, a sign of alcohol intolerance. An associated risk factor to many health conditions.

Alcohol tolerance vs Intolerance

Alcohol tolerance is the ability of the body to metabolize alcohol and reduce its concentration in the blood. When the body and the brain are subjected to alcohol, it activates the liver to produce large amounts of liver enzymes for the breakdown of alcohol to flush out any toxic products of alcohol out of the body.

Alcohol intolerance is the inability of the liver to break down alcohol. It is related to a genetic disorder of aldehyde dehydrogenase gene (ALD­H2) that is responsible for normal functioning of the liver enzymes. Due to its absence, a toxic by-product of alcohol called ac­etalde­hyde builds up in the blood which causes intolerance.

Acetaldehyde in the blood triggers Alcohol flush reaction. It also releases a chemical called histamine in the body that causes inflammation and aids allergic reaction.  

Signs and Symptoms of high levels of blood acetaldehyde

  • Redness and flushing

One of the earliest reaction of Alcohol flush involves a persistently red face (refer Fig 1) due to enlarged blood vessels. This may also be seen on the chest and neck region.

before and after alcohol

Fig 1. Alcohol Flush Reaction

  • Palpitations

Acetaldehyde increases palpitation which is a sensation within the chest that brings awareness of an irregular or racing heartbeats.

  • Increased heart rate

An increase in heart rate is seen with increased levels of acetaldehyde. It causes the blood vessels to dilate, making the heart pump harder and faster for the blood to flow through relaxed blood vessels. 

  • Low blood pressure

Blood pressure is the pressure of blood in the circulatory system. Due to the alcohol reaction, the heart beats faster pumping out less volume of blood and dropping the blood pressure. One may feel light headed and dizzy which can get severe.

  • Extreme drowsiness and headaches

The direct cause is unknown, however, it is believed that due to the expansion of the blood vessels in the brain, histamine release and low blood pressure one may get extreme drowsiness and headaches. 

  • Pruritus (Itching)

This is an unpleasant sensation that provokes the desire to itch or scratch. This happens due to irritated nerve endings on the skin caused by histamine released by the acetaldehyde levels in the blood.

  • Nausea

A feeling of vomiting starts as the acetaldehyde levels in the body irritate the stomach lining, leading to inflammation (gastritis). 

  • Alcohol-induced asthma

Increased levels of acetaldehyde and histamine release in the body can trigger breathlessness due to constriction of the airway. It is often reported to appear after approximately 30 minutes post-alcohol consumption.

Risk Factors associated with people who get Alcohol Flush Reaction 

  • Esophageal Cancer

 Acetaldehyde in the blood is known to interfere with the DNA synthesis and repair mechanism and increases the risk of cancer by producing free radicals that are known to destroy healthy cells.

  • Alzheimer’s disease:

Alzheimer’s disease is a neurological disorder in which the death of brain cells causes memory loss and affects brain function. Research has claimed that genetic disorder related to the aldehyde enzyme also interact with the brain cells which are believed to be a risk factor of Alzheimer’s disease. 

  • Heart disease

 Continual drinking of alcohol among people with Alcohol flush reaction will affect the functioning of the heart and may lead to the risk of heart problems.

  • Liver disease 

Acetaldehyde causes oxygen deficits in the liver (hypoxia), including formation of harmful compounds that damage the cells of the liver leading to a liver disease.

Are you sensitive to alcohol or is it something else? 

If you are only experiencing this reaction with specific alcohol beverages. This may suggest that it is not alcohol intolerance but could be due to other ingredients involved that triggered the reaction. 

What can be done about the Alcohol flush reaction?

There is medication available to help with the flush. However, these drugs can only curb the redness but will not be able to break down the acetaldehyde levels in the body. Thus, individuals who drink often and use drugs to suppress the flushing will still be at risk of developing a health problems.

The best way to prevent alcohol flush reaction and minimise health issues is by not drinking alcohol at all. This may however be an unrealistic solution to many especially during social events.

There are few things one could consider that may help reduce the alcohol flush reaction:

  • Eating before alcohol consumption.
  • Having drinks with lower alcohol content.
  • Alternate alcoholic drinks with water or non-alcoholic drinks.

Like all things, always consume alcohol in moderation. Alcohol is a depressant, but it’s also an indirect stimulant. Never drink and drive. Medication can help mask the reaction but if you feel that it’s more than just a flush, always seek immediate medical attention.