Introduction

Too much stress, too much spicy food, and you may be headed for an ulcer — that was the way the thinking used to go.

Peptic ulcers are open sores that develop on the inside lining of your stomach, upper small intestine or esophagus. The most common symptom of a peptic ulcer is pain.

Not long ago, the common belief was that peptic ulcers were a result of lifestyle. Doctors now know that a bacterial infection or some medications — not stress or diet — cause most ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal ulcers also may occur and are typically associated with the reflux of stomach acid.

Peptic ulcers are common, and oftentimes successful treatment of peptic ulcers takes just a few weeks.

Signs and symptoms

Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:

• Be felt anywhere from your navel to your breastbone
• Last from a few minutes to many hours
• Be worse when your stomach is empty
• Flare at night
• Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication
• Come and go for a few days or weeks

Less often, ulcers may cause severe signs or symptoms such as:

• The vomiting of blood — which may appear red or black
• Dark blood in stools or stools that are black or tarry
• Nausea or vomiting
• Unexplained weight loss
• Chest pain

Causes

Depending on their location, peptic ulcers have different names:

• Gastric ulcer. This is a peptic ulcer that occurs in your stomach.
• Duodenal ulcer. This type of peptic ulcer develops in the first part of the small intestine (duodenum).
• Esophageal ulcer. An esophageal ulcer is usually located in the lower section of your esophagus. It’s often associated with chronic gastroesophageal reflux disease (GERD).

The culprit in most cases
Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that the cause of most ulcers is the corkscrew-shaped bacterium Helicobacter pylori (H. pylori).

H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of the stomach or duodenum, producing an ulcer. One reason may be that people who develop peptic ulcers already have damage to the lining of the stomach or small intestine, making it easier for bacteria to invade and inflame tissues.

H. pylori is a common gastrointestinal infection around the world. In the United States, one in five people younger than 30 and half the people older than 60 are infected. Although it’s not clear exactly how H. pylori spreads, it may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.

H. pylori is the most common, but not the only, cause of peptic ulcers. Besides H. pylori, other causes of peptic ulcers, or factors that may aggravate them, include:

• Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. The medications are available both by prescription and over-the-counter. Nonprescription NSAIDs include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) and ketoprofen (Orudis KT). To help avoid digestive upset, take NSAIDs with meals.NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect your stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.
• Smoking. Nicotine in tobacco increases the volume and concentration of stomach acid, increasing your risk of an ulcer. Smoking may also slow healing during ulcer treatment.
• Excessive alcohol consumption. Alcohol can irritate and erode the mucous lining of your stomach and increases the amount of stomach acid that’s produced. It’s uncertain, however, whether this alone can progress into an ulcer or whether other contributing factors must be present, such as H. pylori bacteria or ulcer-causing medications, such as NSAIDs.
• Stress. Although stress per se isn’t a cause of peptic ulcers, it’s a contributing factor. Stress may aggravate symptoms of peptic ulcers and, in some cases, delay healing. You may undergo stress for a number of reasons — an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury.

When to seek medical advice

An ulcer isn’t something that you should treat on your own, without a doctor’s help. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is short-lived. If you have signs or symptoms of an ulcer, see your doctor. With a doctor’s help, you can find prompt relief of ulcer pain as well as a complete healing of the ulcer.

Screening and diagnosis

In order to detect an ulcer, your doctor may have you undergo the following diagnostic tests:

• Upper gastrointestinal (upper GI) X-ray. Your doctor may begin with this test, which outlines your esophagus, stomach and duodenum. During the X-ray, you swallow a white, metallic liquid (containing barium) that coats your digestive tract and makes an ulcer more visible. An upper GI X-ray can detect some ulcers, but not all.
• Endoscopy. This procedure may follow an upper GI X-ray if the X-ray suggests a possible ulcer, or your doctor may perform endoscopy first. In this more sensitive procedure, a long, narrow tube with an attached camera is threaded down your throat and esophagus into your stomach and duodenum. With this instrument, your doctor can view your upper digestive tract and identify an ulcer.

If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy) near the ulcer. These samples are examined under a microscope to rule out cancer. A biopsy can also identify the presence of H. pylori in your stomach lining. Depending on where the ulcer is found, your doctor may recommend a repeat endoscopy after two to three months to confirm that the ulcer is healing.

Additional tests
In addition to a biopsy, these other tests can determine if the cause of your ulcer is H. pylori infection:

• Blood test. This test checks for the presence of H. pylori antibodies. A disadvantage of this test is that it sometimes can’t differentiate between past exposure and current infection. After H. pylori bacteria have been eradicated, you may still have a positive result for many months.
• Breath test. This procedure uses a radioactive carbon atom to detect H. pylori. First, you blow into a small plastic bag, which is then sealed. Then, you drink a small glass of clear, tasteless liquid. The liquid contains radioactive carbon as part of a substance (urea) that will be broken down by H. pylori. Thirty minutes later, you blow into a second bag, which also is sealed. If you’re infected with H. pylori, your second breath sample will contain the radioactive carbon in the form of carbon dioxide.The advantage of the breath test is that it can monitor the effectiveness of treatment used to eradicate H. pylori, detecting when the bacteria have been killed or eradicated. With the blood test, H. pylori antibodies may sometimes still be present a year or more after the infection is gone.
• Stool antigen test. This test checks for H. pylori in stool samples. It’s useful both in helping to diagnose H. pylori infection and in monitoring the success of treatment.

Complications

Left untreated, peptic ulcers can cause internal bleeding and can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis). Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

Treatment

Because many ulcers stem from H. pylori bacteria, doctors use a two-pronged approach to peptic ulcer treatment:

• Kill the bacteria.
• Reduce the level of acid in your digestive system to relieve pain and encourage healing.

Accomplishing these two goals requires the use of at least two, and sometimes three or four, of the following medications:

• Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn’t sufficient to kill the organism. For the treatment to work, it’s essential that you follow your doctor’s instructions precisely. Antibiotics commonly prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Some companies package a combination of two antibiotics together, with an acid suppressor or cytoprotective agent specifically for treatment of H. pylori infection. These combination treatments are sold under the names Prevpac and Helidac. You’ll likely need to take antibiotics for two weeks, depending on their type and number. Other medications prescribed in conjunction with antibiotics generally are taken for a longer period.
• Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).
• Antacids. Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.
• Proton pump inhibitors. Another way to reduce stomach acid is to shut down the “pumps” within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprozole (Protonix) can be taken orally or administered intravenously in the hospital. Proton pump inhibitors are frequently prescribed to promote the healing of peptic ulcers. If you are admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture.
• Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). In addition to protecting the lining of your stomach and intestines, bismuth preparations appear to inhibit H. pylori activity.

If H. pylori isn’t identified in your system, then it’s likely that your ulcer is due to NSAIDs — which you should quit using, if possible — or acid reflux, which can cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels — through use of acid blockers, antacids or proton pump inhibitors — and may also have you use cytoprotective drugs.

Ulcers that fail to heal
Peptic ulcers that don’t heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. Not taking medications according to directions is one reason. Another is that some types of H. pylori are resistant to antibiotics. Other factors that can interfere with the healing process include regular use of tobacco, alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes the problem is accidental: People are unaware that a medication they’re taking contains an NSAID.

In rare cases, refractory ulcers may be a result of:

• Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
• An infection other than H. pylori
• Stomach cancer
• Other digestive diseases, including Crohn’s disease or cancer

Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn’t respond to aggressive drug treatment.

Self-care

Before the discovery of H. pylori, doctors often advised people with ulcers to eat a restricted diet and reduce the amount of stress in their lives. Now that food and stress have been eliminated as direct causes of ulcers, these factors are no longer of as much importance. However, while an ulcer is healing, it’s still advisable to watch what you eat and to control stress. Acidic or spicy foods may increase ulcer pain. The same is true for stress. Stress may increase acid and slow digestion, allowing food and digestive acid to remain in your stomach and intestines for a longer period. If stress is severe, it may delay the healing of an ulcer.

Your doctor may also give you this advice:

• Don’t smoke. Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid.
• Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding.
• Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If you use pain relievers regularly, use acetaminophen (Tylenol, others).
• Control acid reflux. If you have an esophageal ulcer — usually associated with acid reflux — you can take several steps to help manage acid reflux. These include avoiding spicy and fatty foods, avoiding reclining after meals for at least three hours, raising the head of your bed and reducing your weight. Avoiding smoking, alcohol and NSAIDs also may help to control acid reflux.

Introduction

Nicotine dependence is the physical vulnerability of your body to the chemical nicotine, which is potently addicting when delivered by various tobacco products. Smoke from cigarettes, cigars and pipes contains thousands of chemicals, including nicotine. Nicotine is also found in chewing tobacco.

Nicotine produces physical and mood-altering effects in your brain that are temporarily pleasing; these effects reinforce your continued use of tobacco and nicotine dependence.

Being addicted to tobacco brings you a host of health problems related to the substances in tobacco smoke. These effects include damage to your lungs, heart and blood vessels. Smokers have significantly higher rates of heart disease, stroke and cancer.

Millions of Americans smoke, and smoking is the leading preventable cause of death in the United States. Men who don’t quit smoking lose an average of 13.2 years of life, while smoking women lose even more — an average of 14.5 years.

Overcoming nicotine dependence is difficult and takes commitment, support and time. The sooner you quit smoking, the better. But even if you’re a longtime smoker, stopping your nicotine dependence plus taking healthy lifestyle steps can reverse much of the damage smoking has done to your body.

Signs and symptoms

Nicotine dependence may mean you have these signs and symptoms:

• You can’t stop smoking. You’ve made one or more serious, but unsuccessful, attempts to stop.
• You experience strong withdrawal symptoms when you try to stop. Your attempts at stopping have caused physical signs and symptoms of addiction, such as craving for tobacco, anxiety, irritability, restlessness, difficulty concentrating, headache, drowsiness, stomach upset, even constipation or diarrhea.
• You keep smoking despite health problems. Even though you’ve developed problems with your lungs or your heart, you haven’t stopped or can’t stop.
• You give up social or recreational activities in order to smoke. You may stop going to certain restaurants or stop socializing with certain family members or friends because you can’t smoke in these situations.

Your degree of addiction depends in part on how much you smoke and how long you’ve smoked.

Causes

Tobacco smoke delivers at least 60 known cancer-causing chemicals, tiny amounts of poisons including arsenic and cyanide, and more than 4,000 other substances to your body.

Nicotine is the chemical in tobacco that keeps you smoking. It can be as addictive as cocaine. It increases the release of a brain chemical called dopamine, which makes you feel good. Getting that dopamine boost is part of the addiction process.

Tobacco dependence involves psychological as well as physical factors. You may develop strong, repetitive behaviors associated with smoking. You may smoke at certain times of the day or after a meal or in certain locations or under certain levels of stress. These behaviors and routines that you associate with smoking have to be addressed if you are to overcome your addiction to tobacco.

Risk factors

Anyone who smokes is at risk of becoming addicted to nicotine. Tobacco smoking is a behavior that often becomes established during adolescence. About 90 percent of smokers begin smoking before the age of 21, and many start before age 18.

The younger you begin smoking, the greater the chance that you’ll become a heavy smoker as an adult. In 2004, 22 percent of American high schoolers said they were current smokers, as did nearly 12 percent of American middle-school-age children. While the rate of teen smoking has been declining since the 1990s, the decrease seems to have stalled in recent years. That’s especially bad news because teenagers who smoke are more likely to use alcohol and other drugs.

Youngsters with two smoking parents are twice as likely to pick up the smoking habit themselves. And, children with friends who smoke are also more likely to try cigarettes. Exposure to tobacco in movies or advertisements, particularly for young people, may influence the decision to start smoking or keep smoking.

When to seek medical advice

You may have tried to stop smoking because you’ve experienced health problems related to smoking or because you’re concerned about potential health problems. If you’ve tried to stop, but have discovered you can’t, talk to your doctor about finding a strategy to help you stop successfully.

Complications

When you inhale tobacco smoke, you’re ingesting a chemical parade that will march through most of your body’s vital organs. The negative health effects throughout your body are numerous, including:

• Lungs. Smoking is the cause of most cases of lung cancer. Smoking is also the primary cause of other lung problems, such as emphysema and chronic bronchitis.
• Heart and circulatory system. Smoking increases your risk of dying from cardiovascular disease, including heart attack and stroke. If you smoke more than 25 cigarettes daily, your have five times the risk of heart disease compared to someone who doesn’t smoke. Smoking 15 cigarettes a day doubles your heart attack risk. Even just one to four cigarettes daily increases your risk of heart disease. Smokers have a higher risk of stroke that nonsmokers do; the more you smoke, the higher your risk.
• Cancer. Smoking is a major cause of cancer of the esophagus, larynx, throat (pharynx) and mouth and contributes to cancer of the bladder, pancreas, liver, kidney, cervix, stomach, colon and rectum, and some leukemias.
• Appearance. The chemicals in tobacco smoke can dry and irritate your skin, as well as promote wrinkles. Smoking also yellows your teeth, fingers and fingernails.
• Fertility. Smoking increases the risk of infertility and miscarriage in women and the risk of impotence and infertility in men.
• Pregnancy and newborn complications. Mothers who smoke while pregnant increase the risk of low birth weight, preterm delivery and impaired lung function in their newborns.
• Cold, flu and other illnesses. Smokers are more prone to illnesses, such as colds, flu or bronchitis, than nonsmokers are.
• Senses. Smoking deadens your senses of taste and smell, so food isn’t as appetizing as it once was.

Treatment

Breaking an addiction to nicotine can be very difficult, and many smokers have to make repeated attempts before they’re successful. Quitting smoking is possible, even though it may take more than a few tries. Almost 46 million Americans have quit smoking, and so can you.

The benefits of quitting
Although it may be tough to break your nicotine addiction, the benefits are well worth the effort. If you manage to quit smoking before you’re 35, you’ll miss out on at least 90 percent of the health risks associated with tobacco use. If you quit before you’re 50, you can halve your risk of dying in the next 15 years, compared with those who continue smoking.

But, no matter what your age, your health will benefit if you stop using tobacco. Just 20 minutes after your last cigarette, your heart rate goes down. Twelve hours later, the carbon monoxide levels in your blood return to normal. Your lung function improves and your circulation starts to get better between two weeks and three months after your last cigarette. Between one and nine months after quitting, your risk of infections drops and coughing and shortness of breath decrease. After one year, the risk of coronary artery disease drops by half. And, after five to 15 years, your stroke risk will be the same as that of a nonsmoker.

Methods of quitting are numerous
There are many ways to quit smoking, including using medications and getting some sort of counseling or support.

The approved effective medications to help you stop smoking fall into two categories — nicotine replacement therapy and non-nicotine medications. Any of these effective medications combined with behavioral changes can double your chances of quitting.

Combining medications with follow-up visits to your doctor for support and counseling is usually more successful than is trying to stop on your own. If you’ve tried a medication on your own but haven’t been successful in quitting, talk to your doctor about it. He or she can help you move in the right direction by adjusting the dose of your medication, recommending a different medication, or using a combination of medications.

Nicotine replacement therapy
Most nicotine replacement products are available over-the-counter:

• Nicotine patch (Nicoderm CQ, Nicotrol, Habitrol, others). The patch delivers nicotine through your skin and into your bloodstream. You wear a new patch each day on your upper body. The treatment period may last for eight weeks or longer. Don’t be in a hurry to stop using the patch, especially if you’ve stopped smoking or dramatically reduced your smoking. If you haven’t been able to stop smoking completely after the first week or so of treatment, ask your doctor for help in adjusting the dose of the patch or adding another medication.
• Nicotine gum (Nicorette, others). This is a gum-like resin that delivers nicotine to your blood through the lining of your mouth. It’s available in a 2-milligram dose for regular smokers and a 4-milligram dose for heavy smokers. The maximum number of pieces a day is 20, though you’ll probably chew less. Nicotine gum is recommended for one to three months, with a maximum of six months.
• Nicotine lozenge (Commit). This is a tablet that dissolves in your mouth and, like nicotine gum, delivers nicotine through the lining of your mouth. The lozenges are also available in 2- and 4-milligram doses. The recommended dose is one lozenge every couple of hours for six weeks, then gradually increasing the intervals between lozenges over the next six weeks.

These nicotine replacement products are available by prescription:

• Nicotine nasal spray (Nicotrol NS). The nicotine in this product, sprayed directly into each nostril, is absorbed through your nasal membranes into veins, transported to your heart and then sent to your brain. It’s a quicker delivery system than that of the gum or patch. It’s usually prescribed for three-month periods, for a maximum of six months.
• Nicotine inhaler (Nicotrol inhaler). This device is shaped something like a cigarette holder. You puff on it, and it gives off nicotine vapors in your mouth. You absorb the nicotine through the lining in your mouth, where it then enters your bloodstream and goes to your brain, relieving withdrawal symptoms.

Non-nicotine medication
Medications that don’t contain nicotine include:

• Antidepressants. The antidepressant drug bupropion increases the level of dopamine, the chemical that’s also boosted by nicotine, in your brain. As with many medications, bupropion (Zyban) has side effects, including sleep disturbance and dry mouth. If you have a history of seizures or serious head trauma, such as a skull fracture, don’t use this drug. Another antidepressant that may help is nortriptyline (Aventyl, Pamelor).
• Varenicline (Chantix). This medication acts on the brain’s nicotine receptors, decreasing withdrawal symptoms and reducing the feelings of pleasure you get from smoking. Potential side effects include headache, nausea, an altered sense of taste and strange dreams.
• Nicotine vaccine. The nicotine conjugate vaccine (NicVax) is under investigation in clinical trials. This vaccine causes the immune system to develop antibodies to nicotine. These antibodies then catch nicotine as it enters the bloodstream and prevent the nicotine from reaching the brain, effectively blocking the effects of nicotine.

Counseling, support groups and smoking cessation programs
Many people need help to quit smoking. A number of telephone help lines are available for people giving up nicotine, such as the National Cancer Institute’s 800-QUITNOW, or 800-784-8669, and the American Cancer Society’s at 800-ACS-2345, or 800-227-2345.

Your doctor may also be able to recommend local support groups or smoking cessation programs. Additionally, some people find that a form of counseling called behavior therapy can help them come up with productive ways to change the behaviors and thoughts associated with smoking.

Prevention

The best way to prevent tobacco dependence is to not smoke in the first place. The best way to prevent your children from smoking is to not smoke yourself. If you’re a parent who smokes, the younger your children are when you quit, the less likely they are to become smokers themselves. Even if you don’t smoke, here are some strategies you might try as a parent:

• Talk with your teenagers. Ask whether their friends smoke. The risk of your child smoking is higher if his or her friends smoke. Most teenagers smoke their first cigarette with a friend who already smokes.
• Learn what your children think about smoking. Ask them to read this information so that you can discuss it together. Emphasize that research has found teens can show signs of tobacco dependence after smoking intermittently for only a few weeks.
• Help your children explore personal feelings. Use nonjudgmental questions and rehearse with them how they could handle tough situations regarding peer pressure and smoking.
• Encourage your teenager to enjoy maximal energy and health. Explain to your teenager that the active, vivacious lifestyles portrayed in many cigarette advertisements are actually more representative of nonsmokers. People who smoke have colds and other respiratory infections more frequently.
• Note the social repercussions. Remind your teenager that smoking gives you bad breath and makes your hair and clothes smell.
• Work with your schools. Become active in community stop-smoking programs.
• Promote smoke-free environments. Encourage public areas and restaurants, including places where your teen may work, to offer smoke-free environments. This helps to denormalize smoking, reducing the chances your teen will start and helping smokers to stop.

Self-care

When you stop smoking, you’ll likely experience signs and symptoms of nicotine withdrawal. Your body is accustomed to regular, high doses of nicotine. It sends out distress signals when those levels of nicotine aren’t present. Use of medications will markedly reduce withdrawal. Even so, it’s important to know how to manage withdrawal symptoms.

Withdrawal symptoms are usually the most intense during the first three days after you stop smoking. But they may continue for several weeks, although at a declining level of intensity. Although most nicotine withdrawal symptoms pass within four weeks, you may experience periodic cravings, or strong urges to smoke, even months after stopping. Triggers or cues that were associated with smoking can provoke the cravings.

Most people who try to stop smoking experience a range of withdrawal signs and symptoms. Here are some of the more common ones and things you can do to deal with them:

Physical discomfort or depression

• Exercise. Even taking a brisk, 30-minute walk can help.
• Talk to a support person.

Insomnia

• Reduce or avoid caffeine or other stimulants.
• Relax before going to bed.
• Don’t eat, watch television or discuss problems in bed.
• Make your bedroom quiet and comfortable.
• Keep a regular bedtime routine.
• Write down your worries on a piece of paper and leave them in another room.

Irritability, frustration, anger

• Use relaxation techniques.
• Exercise regularly.
• Try deep breathing.
• Reduce caffeine or other stimulants.
• Avoid stressful situations.

Anxiety, nervousness

• Use relaxation techniques.
• Exercise regularly.
• Try deep breathing.
• Reduce caffeine or other stimulants.
• Talk to a support person.
• Use distractions.

Difficulty concentrating

• Adjust your schedule to a lighter workload.
• Lower expectations on the amount of work you can do.
• Understand the amount of energy and time it takes to stop smoking.

Restlessness, impatience

• Take short exercise breaks. This not only takes you away from the situation, but helps you relieve withdrawal symptoms.
• Try deep breathing.
• Avoid caffeine or other stimulants.
• Change focus of attention frequently.

Increased appetite

• Eat healthy snacks.
• Don’t delay regular meals.
• Drink more water.
• Exercise regularly.

Cravings for tobacco, desire to smoke

• Wait out the craving, which is usually less than five minutes.
• Try deep breathing.
• Use distractions.

Change in bowel habits, such as constipation

• Maintain a diet of regular meals and drink plenty of fluids.
• Use bulk-producing foods.
• Limit gas-producing foods.
• Limit gum chewing.

Fatigue

• Exercise regularly.
• Eat regular meals.
• Plan more rest and take short naps.

Cough, dry throat, nasal drip, clearing throat

• Drink water.
• Use cough drops to relieve throat irritation.

Coping skills

Many smokers yearn to stop but find it hard because of nicotine’s powerful addictive hold. You may need more than one attempt before you successfully stop.

Maybe you want to stop smoking but don’t feel ready to stop right now. Many smokers experience similar feelings. Although they want to stop, most also have reasons to put off taking action. The good news is, most smokers eventually do stop. But how can you build the motivation to make the change now?

Start by addressing the mixed feelings you may have about smoking. Identify the reasons why you’d like to continue and the reasons why you’d like to stop. Make a list of your barriers and benefits to making a change. Continue to update the list as you think of more reasons.

Identify barriers
These barriers are real for you and may make you hesitant to change your smoking behavior. But by identifying barriers before you try to stop smoking, you can:

• Start thinking of ways to overcome these barriers. You may even decide that some barriers aren’t as big as you had originally thought. You may be able to control weight gain with just a little extra exercise.
• Already start working on overcoming certain barriers. For example, if you’re concerned about a lack of social support, talk to a friend who used to smoke or to a health care professional. If you’re worried about the discomfort of withdrawal symptoms, consider the use of nicotine replacement or bupropion to help.
• Develop strategies to build confidence to overcome barriers. For example, in situations that trigger your urge to smoke, think of alternatives.
• Set smoke-free boundaries. If there’s another smoker in your household, set boundaries by making your home and car smoke-free.

Identify benefits
Stopping smoking is a good change for many reasons. Identify the reasons that are important to you.

• First, make a list. Think of short-term benefits (such as breathing easier, saving money, no more smoky-smelling clothes) and long-term benefits (lower risk of disease, increased chances for a longer life, no secondhand smoke affecting the health of your loved ones).
• This list gives you strong reasons. Whether your list is long or short, the better you’re able to identify the benefits of stopping, the stronger your reasons are to stop.
• These reasons build your motivation. Remind yourself of these reasons regularly, especially when you feel your motivation to make a change is lagging.

Build self-confidence
You may have little confidence in your ability to stop smoking. You may have tried to stop many times. If so, try to change your perspective. Instead of thinking of stopping as a huge, impassable obstacle, focus on the smaller details. Identify specific situations in your day that could help or harm your attempt to stop. For example, you may feel confident that you can stay smoke-free in certain situations, such as at your work desk, but less confident about other situations, such as at a party. Take these actions to build self-confidence:

• Identify your major areas of concern. This will help you problem solve and develop strategies to stop smoking.
• Identify situations in which you have some confidence. You’ll find that you have many situations in which you’re already able to stay smoke-free.
• Seek support. As you work on stopping, seek the social support you need and practice your new coping strategies. In this way, you’ll increase your confidence in being able to make a move toward being smoke-free.

Are you giving yourself enough support and encouragement? Make sure to send yourself positive messages about stopping.

• Develop a positive attitude by practicing positive self-talk. Start by looking in the mirror and saying, “I can stop smoking” or “I can be smoke-free.”
• Think of one or two phrases to use repeatedly for encouragement. Examples are: “I can make it” and “Keep it up.”

Complementary and alternative medicine

While there’s no solid evidence that any complementary or alternative medicine therapy is effective for smoking cessation, some people have found methods such as acupuncture or hypnosis to be helpful. Ask your doctor for a referral to a reputable practitioner, and be wary of any treatment method that promises to make quitting smoking easy.

Introduction

Small and out-of-sight, but painful, persistent and annoying. That’s what canker sores, also called aphthous ulcers (aphthae), are for people who experience them. These shallow ulcers in your mouth can make eating and talking uncomfortable. They may occur on your tongue, on your soft palate, inside your cheeks or lips, and at the base of your gums.

Canker sores differ from cold sores in that they occur on the internal soft tissues of your mouth and aren’t contagious. Conversely, cold sores almost always start out on the lips and don’t often spread to the soft tissues of your mouth. In addition, cold sores are caused by a form of the herpes virus, making them extremely contagious.

Canker sores are common, but the cause in many cases is unknown. Canker sores can occur at any age, but often they first appear when you are between 10 and 40 years of age.

Most of the time, treatment isn’t necessary for canker sores. Pain usually decreases after several days, and canker sores typically heal within one to three weeks. Occasionally canker sores can develop that are larger than 1 centimeter in diameter or last longer than two weeks.

Signs and symptoms

Signs and symptoms of canker sores may include:

• Painful sore or sores inside your mouth — on your tongue, under your tongue (soft palate), inside your cheeks or lips, and at the base of your gums
• Tingling or burning sensation prior to appearance of the sores
• Round, white sores with a red edge or halo

You also may experience the following signs or symptoms, though they may not be related to the canker sores:

• Fever
• Listlessness
• Swollen lymph nodes

Causes

The cause of most canker sores remains a mystery.

Researchers generally believe that stress or tissue injury may cause the eruption of canker sores. A minor injury — caused by biting the inside of your mouth or by eating rough foods, such as nuts — may trigger a canker sore. Other causes may include:

• Faulty immune system function
• Nutritional problems, such as a deficiency of vitamin B-12, zinc, folic acid or iron
• A disease of the gastrointestinal tract
• Food allergies
• Menstrual periods

Though anyone can get cankers sores, they tend to run in families and may be an inherited condition.

When to seek medical advice

If you experience any of the following conditions, see your doctor:

• Unusually large sores
• Persistent sores, lasting three weeks or more
• Pain that you can’t control with self-care measures
• Difficulty drinking enough fluids
• High fever with canker sores

In such cases, the sore may be a sign of some other medical condition. See your dentist if you have sharp tooth surfaces or dental appliances that seem to trigger the sores.

Treatment

Often treatment isn’t necessary and your canker sore will heal on its own. Your doctor may suggest prescription medication if your sores are large, painful or persistent. To relieve the pain and irritation of canker sores, your doctor may recommend a prescription mouthwash, a corticosteroid salve or an anesthetic solution.

Prevention

Canker sores can recur, but you may be able to reduce their frequency by addressing factors that seem to trigger canker sores:

• Watch what you eat. Avoid foods that seem to irritate your mouth. These may include acidic foods, nuts and certain spices.
• Don’t chew and talk at the same time. You could cause minor trauma to the delicate lining of your mouth, triggering a canker sore.
• Follow good oral hygiene habits. Regular brushing after meals and flossing once a day can keep your mouth clean and free of foods that might trigger a sore. Using a soft brush may help you avoid irritation of mouth tissues.

Self-care

The following practices may provide temporary relief of canker sores:

• Avoid abrasive, acidic or spicy foods, which may increase the pain.
• Apply ice to your canker sores or allow ice chips to slowly dissolve over the sores to ease the pain.
• Brush your teeth gently, using a soft brush to avoid irritating the sore.
• Rinse your mouth with salt water or over-the-counter preparations. Try diluted hydrogen peroxide or elixir of diphenhydramine (Benadryl). Be sure to spit the Benadryl out to avoid absorption, so that the medication doesn’t make you sleepy.
• Dab a small amount of milk of magnesia on your canker sore a few times a day. This can ease the pain and may help the canker sore to heal.
• Use an over-the-counter pain reliever, such as aspirin, acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others). But don’t give aspirin to children. Aspirin may trigger a rare, but potentially fatal, disorder known as Reye’s syndrome.

Introduction

“Thrombo” means “clot.” Phlebitis is inflammation of a vein. Thrombophlebitis (throm-bo-fluh-BI-tis) occurs when a blood clot causes inflammation in one or more of your veins, typically in your legs. On rare occasions, thrombophlebitis (often shortened to “phlebitis”) can affect veins in your arms or neck.

The affected vein may be near the surface of your skin, causing superficial thrombophlebitis, or deep within a muscle, causing deep vein thrombosis (DVT). A clot in a deep vein increases your risk of serious health problems, including a dislodged clot (embolism) traveling to your lungs and blocking a pulmonary artery (pulmonary embolism).

Thrombophlebitis often is caused by prolonged inactivity, such as from sitting during a long period of travel in an airplane or automobile or from lengthy bed rest after surgery. Such inactivity decreases blood flow through your veins and may cause a clot to form. Paralysis, certain types of cancer and use of the hormone estrogen also may lead to thrombophlebitis. An inherited tendency for blood clots places you at higher risk of thrombophlebitis.

You can use self-care methods to ease pain and reduce your risk of clots. Various treatments, including medications and surgery, also are available for thrombophlebitis.

Signs and symptoms

Signs and symptoms of thrombophlebitis include:

• Warmth, tenderness and pain in the affected area
• Redness and swelling

When a superficial vein is affected, a red, hard and tender cord may be present just under the surface of your skin. When a deep vein in the leg is affected, your leg may become swollen, tender and painful, most noticeably when you stand or walk. You may also have a fever. However, many people with deep vein thrombosis have no symptoms.

Risk factors

The cause of thrombophlebitis is a blood clot. Blood clots can result from many different things — namely anything that causes your blood not to circulate properly. Your risk of thrombophlebitis increases if you:

• Are inactive for a long period of time, such as from sitting in a car or an airplane
• Are confined to bed for a prolonged time, such as after surgery, a heart attack or a leg fracture
• Have a type of cancer, such as pancreatic cancer, that may cause an increase of procoagulants — substances necessary for blood clotting (coagulation) — in your blood
• Have had a stroke that resulted in paralysis of your arms or legs
• Have a pacemaker or have a thin, flexible tube (catheter) in a central vein, for treatment of a medical condition, which may irritate the blood vessel wall and decrease blood flow
• Are pregnant or have just given birth, which may mean you have increased pressure in the veins of your pelvis and legs
• Use oral contraceptives or hormone replacement therapy, which may increase the clotting factors in your blood
• Have a family history of a blood-clotting disorder or a tendency of blood clots
• Are overweight or obese
• Have varicose veins — clots may develop in dilated superficial veins (varicose veins), causing superficial thrombophlebitis
• Are a smoker

The more risk factors you have, the higher your risk of thrombophlebitis. If you have one or more risk factors, be sure to discuss prevention strategies with your doctor before long periods of inactivity, such as a long flight, a long car ride or after an elective surgery.

When to seek medical advice

See your doctor if you have a red, swollen or tender vein — especially if you have one or more risk factors for thrombophlebitis. If vein swelling and pain are severe or are accompanied by a high fever or shortness of breath, go to an emergency room. These signs and symptoms may indicate deep vein thrombosis, which increases your risk of a dislodged blood clot traveling through your bloodstream to your lungs.

Screening and diagnosis

To diagnose thrombophlebitis, your doctor will ask you about the discomfort you’ve experienced and then examine any affected veins near the surface of your skin. To determine whether you have superficial or deep vein thrombosis, your doctor may choose one of these methods:

• Ultrasound. A wand-like device (transducer) placed over your leg sends sound waves into your leg. As the sound waves travel through your leg tissue and reflect back, a computer transforms the waves into a moving image on a video screen. A clot may be visible in the image.
• CT or MRI scans. Both computerized tomography (CT) and magnetic resonance imaging (MRI) can provide visual images of your veins and may show if a clot is present. Sometimes a venous thrombosis is found when these scans are performed for other reasons.
• Venography. A dye (contrast agent) is injected into a large vein in your foot or ankle. An X-ray procedure creates an image of the veins in your legs and feet, to look for clots. This test is used less frequently today because less invasive studies can usually confirm the diagnosis.
• Blood test. Almost all people who develop acute thrombosis have an elevated blood level of a clot-dissolving substance called D dimer. However, D dimer is elevated in other conditions, too. Thus, although a test for D dimer is very sensitive, it’s not very conclusive. Currently, it’s most useful for ruling out deep vein thrombosis or for identifying people at risk of recurrence.

Complications

If thrombophlebitis is in a superficial vein, just under your skin, serious complications are rare. However, if the clot occurs in a deep vein, the risk of serious complications is greater. Complications may include:

• Pulmonary embolism. If part of a deep vein clot becomes dislodged, it may travel to your lungs, where it can block an artery and cause a potentially life-threatening situation.
• Heart attack or stroke. If you have certain types of congenital heart defects that have caused a hole in your heart — such as a patent foramen ovale (PFO), an atrial septal defect or a ventricular septal defect — a traveling clot can enter your coronary arteries or brain and cause a heart attack or stroke.

A deep vein thrombosis also may damage valves in the veins in your legs. Veins have valves to prevent blood from flowing back as it is gradually pushed uphill toward your heart. When the valves in the veins of your legs don’t work properly, several problems can occur:

• Varicose veins. The pooling of blood can lead to ballooning of the veins, resulting in varicose veins.
• Swelling. In some cases, the pooling may become so bad that your leg swells (edema).
• Skin discoloration. With chronic swelling and increased pressure on your skin, discoloration called stasis pigmentation may occur. In some cases, skin ulcers may develop.
• Vein obstruction. Deep vein thrombosis can cause a permanent obstruction to develop in the vein.

Treatment

If thrombophlebitis occurs in a superficial vein, your doctor may recommend self-care steps that include applying heat to the painful area, elevating the affected leg and using a nonsteroidal anti-inflammatory drug. The condition usually subsides within a week or two.

Your doctor may also recommend these treatments for thrombophlebitis:

• Medications. If you have deep vein thrombosis, injection of a blood-thinning (anticoagulant) medication, such as heparin, will prevent clots from growing. After the heparin treatment, taking the anticoagulant warfarin (Coumadin) for several months continues to prevent clots from growing. Sometimes, you may need a drug to dissolve the clot.
• Support stockings. These help prevent recurrent swelling and reduce the chances of complications of deep vein thrombosis. Your doctor may recommend prescription-strength support hose.
• Filter. In some instances, especially if you can’t take blood thinners due to a bleeding condition, a filter may be inserted into the main vein in your abdomen (vena cava) to prevent clots that break loose in leg veins from lodging in your lungs.
• Varicose vein stripping. Your doctor can surgically remove varicose veins that cause pain or recurrent thrombophlebitis in a procedure called varicose vein stripping. This procedure, typically done on an outpatient basis, involves removing a long vein through small incisions. Usually, you’re able to resume normal activities in two weeks or less. Removing the vein won’t affect circulation in your leg because veins deeper in the leg take care of the increased volumes of blood. This procedure is also commonly done for cosmetic reasons.
• Clot removal or bypass. Sometimes, surgery is necessary to remove an acute clot blocking a pelvic vein or an abdominal vein. To treat a blocked vein that is chronic and disabling, your doctor may recommend surgery to bypass the vein, or a nonsurgical procedure called angioplasty to open up the vein. Once angioplasty has opened up the vein, your doctor inserts a small wire mesh tube (stent) to keep the vein open.

Prevention

Quit smoking if you’re a smoker because smoking increases your risk of a blood clot.

Sitting during a long flight or car ride can cause swollen ankles and calves. The inactivity also increases your risk of thrombophlebitis in the veins of your legs. To help prevent a blood clot from forming:

• Take a walk. If you’re flying, walk around the airplane cabin once an hour or so. If you’re driving, stop every hour and walk around the car a couple of times.
• If you must stay seated, move your legs regularly. Flex your ankles, or press your feet against the seat in front of you at least 10 times each hour.

On flights or car rides lasting more than four hours, take additional precautions to reduce your risk of deep vein thrombosis. These include:

• Avoid wearing tight clothing around your waist.
• Drink plenty of fluids to avoid dehydration.
• Stretch your calves by walking at least once an hour.

If you’re at increased risk of deep vein thrombosis, talk to your doctor before your flight. He or she may recommend:

• Compression stockings
• Low-molecular heparin given before departure

Aspirin therapy is generally not recommended, and could thin your blood excessively if you’re also taking warfarin (Coumadin). However, if you are on aspirin for other reasons, such as a heart attack, you should continue taking it.

Self-care

If you have superficial thrombophlebitis:

• Use a warm washcloth to apply heat to the involved area several times daily.
• Elevate your leg.
• Use a nonsteroidal anti-inflammatory drug (Advil, Motrin, others) if recommended by your doctor.

If you have deep vein thrombosis:

• Take prescription anticoagulant medications as directed to prevent recurrences and complications.
• Elevate your leg if it’s swollen.
• Wear your prescription support stockings daily.

Introduction

Doctors today refer to it as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. Parvovirus infection is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases with similar rashes. The other four are measles, rubella, scarlet fever and Dukes’ disease.

Whatever the name, parvovirus infection is still a common but mild infection in children that generally requires little treatment. However, parvovirus infection in some pregnant women can lead to serious health problems for the fetus. Parvovirus infection is also more serious for people with certain anemias or with a compromised immune system.

Signs and symptoms

Early phase of parvovirus infection
Most children with parvovirus infection feel well. Some develop mild, cold-like signs and symptoms early in the illness, and these initial parvovirus symptoms typically last five to 10 days. They may include:

• Sore throat
• Slight fever
• Upset stomach
• Headache
• Fatigue
• Itching

Following phases

• Several days later, a distinctive bright red facial rash usually appears on both cheeks.
• Eventually, the rash may extend to the arms, trunk, thighs and buttocks, where the rash has a pink, lacy, slightly raised appearance.

Generally, the rash occurs near the end of the illness. It’s possible to mistake the rash for other viral rashes or a medicine-related rash. Infants and toddlers develop the same signs and symptoms as do school-age children. The rash may come and go for up to three weeks, becoming more visible when a child is exposed to extreme temperatures or spends time in the sun.

In adults
In adults, the most prominent symptom of parvovirus infection is joint soreness (arthralgia), lasting days to weeks. Joints most commonly affected are the hands, wrists, knees and ankles.

Asymptomatic parvovirus infection
Parvovirus infection can also occur without any signs or symptoms in either children or adults.

Causes

The human parvovirus B19 causes parvovirus infection. This isn’t the same as the parvovirus seen in dogs and cats, so you can’t get the infection from a pet or vice versa.

Parvovirus spreads from person to person, just like a cold, often through respiratory secretions and hand-to-hand contact. The illness is contagious in the week before the rash appears. Once the rash appears, the person with the illness is no longer considered contagious and doesn’t need to be isolated.

Parvovirus B19 is most common among elementary school-age children during outbreaks in the winter and spring months, but anyone can become ill with it anytime of the year.

When to seek medical advice

For your child
If your child develops what appear to be signs and symptoms of parvovirus infection, but you’re not sure, contact your doctor to see if there may be some other cause for the signs and symptoms. Also contact your doctor if your child has a temperature greater than 102 F (38.9 C) or if you have other concerns.

If you have anemia
If you have sickle cell disease or a similar type of chronic anemia, parvovirus infection can lead to severe anemia. See your doctor for treatment. Once the infection is under control, the anemia will get better.

If you’re pregnant
If you’re pregnant and you suspect you’ve been exposed to parvovirus, see your doctor. A pregnant woman with parvovirus infection may pass the illness along to her baby. Although the great majority of pregnant women who have parvovirus infection will deliver normal, healthy children, there’s a small risk to the unborn baby of severe and even life-threatening health conditions.

If your immune system is weak
Also, see your doctor for help with treatment if you have a weakened immune system, perhaps because of another preexisting disease, cancer treatment or an organ transplant.

Screening and diagnosis

If a rash is present, your doctor may be able to make a diagnosis by examination. About half of adults are immune to parvovirus infection, most likely because of a previous, unnoticed, childhood infection.

If you’re pregnant or if you’re an adult with a compromised immune system, blood tests can help determine if you’re immune to the infection or if you’ve recently become infected. The blood tests commonly used are tests for antibodies that are specific for parvovirus infection. Subsequent action depends on test results:

• If the blood tests indicate immunity, you don’t need to be concerned. You can’t be reinfected.
• If the tests confirm evidence of recent parvovirus infection, you may need additional testing to determine what, if any, complications — such as anemia — need treatment.
• If you’re pregnant and you have parvovirus infection, your doctor may perform additional tests, such as ultrasound and possibly additional blood tests, to watch for potential fetal complications.

Complications

Complications related to pregnancy
If you’re pregnant and you become infected with parvovirus B19, particularly during the first half of your pregnancy, there’s a chance your baby may develop serious complications, such as severe anemia. But this occurs in only a small percentage of infected pregnant women.

Fetal anemia can cause congestive heart failure in your baby, manifested by a severe form of edema — swelling of body tissues due to excessive fluid — called fetal hydrops, which may lead to miscarriage. If you have parvovirus infection, your doctor may monitor your pregnancy with ultrasound examinations for the possible development of fetal complications.

The fetal anemia, congestive heart failure and edema can improve over several weeks. Your doctor may suggest steps to try to correct these problems. Possible approaches include a blood transfusion directly to your fetus or giving you medications that pass through your placenta to your fetus.

Most pregnant women with parvovirus infection have normal, healthy babies. Parvovirus infection doesn’t increase the risk of birth defects or mental retardation.

Other complications in adults
Other complications in adults include the following:

• If you have sickle cell anemia or other types of anemia in which red blood cells are used up faster than your bone marrow can replace them, parvovirus infection can lead to severe anemia.
• If you have a weakened immune system, particularly if you’ve undergone chemotherapy, signs and symptoms of the infection can be severe, requiring medical care.

Treatment

For a noncomplicated parvovirus infection, sufficient parvovirus treatment generally consists of self-care steps at home. The rash itself doesn’t need treatment.

If you have severe anemia you may need to be hospitalized and receive blood transfusions. If you have a weakened immune system you may receive antibodies (via immune globulin) to treat your infection.

If you’re pregnant and develop parvovirus infection, your doctor may monitor possible effects on your baby. Treatments may include blood transfusions and medications if your baby has anemia, congestive heart failure or edema.

Prevention

There’s no vaccine to prevent parvovirus infection. Once you’ve become infected with parvovirus, you acquire lifelong immunity. Washing your hands and your child’s hands frequently may help diminish the chances of getting an infection. Throw away used tissues immediately after use — and wash your hands after handling them.

Self-care

Self-care treatment is aimed primarily at relieving signs and symptoms and easing any discomfort. Make sure you or your child gets plenty of rest and drinks lots of fluids. You can use acetaminophen (Tylenol, others) to relieve temperatures of more than 102 F (38.9 C) or minor aches and pains. Avoid giving aspirin to children. Aspirin may trigger a rare but potentially fatal disorder known as Reye’s syndrome.

It’s impractical and unnecessary to isolate your sick child. You won’t know your child has parvovirus infection until the rash appears, and by that time, your child is no longer contagious.

Introduction

Hurthle cell cancer (HCC) is a rare form of cancer affecting the butterfly-shaped thyroid gland in the front part of the lower neck. The thyroid secretes hormones that are essential for regulating your body’s metabolism.

Among new cases of thyroid cancer, less than 5 percent are Hurthle cell cancers. The condition is also called Hurthle cell carcinoma and sometimes oxyphil cell carcinoma.

Hurthle cell cancer can be aggressive, and surgery to remove the thyroid gland is the most common treatment. Most people with Hurthle cell cancer have a good prognosis, but the outlook for Hurthle cell cancer is better the earlier that a diagnosis occurs.

Signs and symptoms

A number of signs and symptoms are associated with thyroid cancer — and specifically Hurthle cell cancer — although these characteristics may not be present in the earliest phases of the disease. These same signs and symptoms may also be indications of other medical conditions — such as an infection of the thyroid gland or a noncancerous enlargement of the thyroid (goiter).

Signs and symptoms of Hurthle cell cancer may include:

• A fast-growing lump (nodule) in your neck, just below your Adam’s apple (the most common clinical sign)
• Enlarged and swollen lymph nodes in your neck
• Pain in your neck or throat, with pain sometimes extending to your ears
• Hoarseness or other changes in your voice
• Shortness of breath
• Trouble swallowing
• A continuous cough not associated with an upper respiratory infection

Causes

The precise cause of Hurthle cell cancer is not known, although researchers believe the disease is associated with alterations in DNA, including some related to the aging process.

DNA is the genetic material that contains the instructions for every chemical process in your body. Some of the genes in your DNA promote cell division, and some slow cell division or program cells to die at the right time. Still other genes control processes that help repair DNA. When DNA is altered or damaged, these genes may not function properly, causing cells to grow out of control and eventually form a mass (tumor) of cancerous (malignant) cells.

Like other thyroid cancers, Hurthle cell cancer has been linked to radiation exposure.

Doctors still have unanswered questions about Hurthle cell cancers, including how to classify them. Hurthle cell cancer is often considered a subgroup of follicular tumors of the thyroid, which develop in the thyroid’s follicle cells. These are cells in which thyroid hormones — thyroxine and triiodothyronine — are manufactured. Some researchers, however, believe that Hurthle cell cancer should be considered a distinct category of thyroid malignancies.

Risk factors

Some studies have suggested the following factors can raise your likelihood of developing Hurthle cell cancer:

• Being female
• Older age
• Radiation treatments to the head and neck

When to seek medical advice

If you have any signs or symptoms associated with Hurthle cell cancer, contact your doctor. An evaluation by your doctor and appropriate diagnostic tests can determine whether these signs or symptoms are caused by Hurthle cell cancer or another medical condition.

Most people with Hurthle cell cancer have a good prognosis and excellent long-term survival. However, if Hurthle cell cancer is diagnosed in its later stages, the outlook may be poorer than for other forms of thyroid cancer.

Screening and diagnosis

If your doctor suspects Hurthle cell cancer, the first steps will be to obtain your medical history and conduct a physical exam. Your doctor will examine your neck, checking the size of your thyroid and seeing whether lymph nodes in the neck are swollen. He or she will also likely order blood tests to check your thyroid function.

To help make a definite diagnosis, your doctor may recommend one or more of the following tests:

• Ultrasound scan. This painless imaging technique, also called a sonogram, uses high-frequency sound waves to outline the neck anatomy and detect a thyroid tumor. A doctor or person who is trained to perform ultrasound exams (sonographer) will place gel on your neck and then place a hand-held transducer on the area. The transducer transmits sound waves into the neck region and sends information to a computer to create a series of pictures of the thyroid — including images of its shape and size.While very good at identifying whether a tumor is present, ultrasound scans can’t tell for sure whether a growth or nodule is malignant or benign. Ultrasound is safe, with virtually no complications associated with its use.
• Fine-needle aspiration (FNA) biopsy. This test may determine whether a tumor or nodule is cancerous or noncancerous. In this procedure, you lie down and the doctor passes a fine needle through the skin of your neck. Your doctor may use ultrasound imaging to help direct the needle into the tumor. As the needle is withdrawn, cellular material is taken out (aspirated). Then the process is repeated to obtain cells from several regions of the growth.These cell samples are placed on glass slides and sent to a laboratory for microscopic analysis to determine whether the nodule is cancerous. In many instances, the results of the biopsy are inconclusive, and the test may need to be repeated or surgical removal of the nodule may be necessary to confirm whether cancer is present. Most tumors turn out to be benign.

  Fine-needle aspiration can be performed in your doctor’s office or at an ambulatory surgical center. Because the needle is very thin (much thinner than a needle used to withdraw blood from your arm), it causes only slight discomfort. Your doctor may apply a local anesthetic to the area to eliminate any chance of pain. Some people experience a small amount of temporary bleeding, bruising or swelling at the site where the needle was inserted.

You won’t need to do much preparation for either of these tests. No fasting is required. In most cases, you won’t need to stop taking any medications.

Other diagnostic tests also may be used, including:

• Magnetic resonance imaging (MRI)
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan

Complications

Possible complications of Hurthle cell cancer and other thyroid tumors include:

• Difficulty swallowing and breathing. This can occur if the tumor grows and presses on the esophagus.
• Spread of the cancer. If Hurthle cell cancer isn’t treated appropriately, or if treatment begins late, the cancer can spread (metastasize) to other tissues and organs, making therapy more difficult and diminishing the chances of recovery.

Treatment

Several approaches are available to treat Hurthle cell cancer:

• Surgery. Surgery is the best treatment for Hurthle cell cancer. During this operation all or nearly all of the thyroid gland is removed, in a procedure is called a near total thyroidectomy. The surgeon leaves tiny edges of thyroid tissue near the adjacent parathyroid glands to lower the likelihood of parathyroid injury. These small parathyroid glands regulate your body’s calcium level. Surrounding lymph nodes are removed to determine if the cancer has spread to them.Before the surgery, your doctor will conduct a complete physical exam, including a heart evaluation to determine the risk of cardiac complications during the operation. Blood tests can reveal if you have a bleeding disorder that could become problematic. You’ll be asked to avoid eating and drinking, beginning the night before the operation.

  The greatest risk associated with the operation is unintended injury to the recurrent laryngeal nerve, which could cause temporary or permanent hoarseness or a loss of your voice. Other complications include damage to the parathyroid, excessive bleeding and infection. You’ll probably need to stay in the hospital for a day or two after the operation to ensure that post-surgical bleeding hasn’t occurred and that you’re able to breathe normally.

• Thyroid hormone medication. After surgery for Hurthle cell cancer, your doctor will prescribe the synthetic drug levothyroxine (Levoxyl, Synthroid, Levothroid), which replaces the hormones no longer being produced because of the absence of the thyroid. You’ll need to take these synthetic hormones for the rest of your life. These medications are safe, and blood tests help determine the correct dose, which minimizes the risk of side effects.
• Radioactive iodine therapy. Radiation therapy using a capsule containing radioactive iodine 131 is often prescribed as an adjunct to surgery for Hurthle cell cancer. It can be used to destroy any microscopic thyroid tissue remaining after the operation, using a modest dose of radiation in a procedure called “remnant ablation.” At times, a higher dose of radioiodine can be used to eliminate any malignant cells that have spread to other parts of the body, such as the lungs and bones.Radioactive iodine therapy is typically administered about six weeks after surgery, generally as an outpatient procedure.

  In rare cases, radioiodine therapy can cause temporary side effects including sore throat, dry mouth, decrease in taste sensations, neck tenderness, nausea and vomiting. Nearly all traces of the radioactive iodine are excreted from the body within about two days after the start of treatment. Doctors avoid this form of treatment in pregnant and breast-feeding women because of risks to the fetus and newborn. Women are advised to wait at least six months before attempting to conceive, and men are advised to wait several months before attempting conception.

• External beam radiation. This approach delivers radiation treatment to attack malignant cells. It’s sometimes an option for people in whom radioiodine therapy hasn’t been successful. It uses a special X-ray machine called a linear accelerator to deliver radiation to cancer cells. This treatment can target specific areas where cancer cells are present, minimizing damage to nearby healthy tissue. Side effects may include fatigue and a temporary reddening and sensitivity of the skin.

Prevention

There are few specific measures you can take to prevent Hurthle cell cancer. However, you may be able to lower your risk by reducing your exposure to radiation from X-rays and other sources whenever possible.

Complementary and alternative medicine

Although many alternative or nontraditional treatments — from vitamins to herbs — are sometimes promoted for use in patients with cancer, none has been proved helpful in the management of Hurthle cell cancer or other types of thyroid cancer. If you have questions about a specific alternative treatment, talk with your doctor.

Introduction

Complex regional pain syndrome (CRPS) is an uncommon, chronic condition that usually affects your arm or leg. Rarely, the disease can affect other parts of your body. You may experience intense burning or aching pain along with swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area.

The nature of complex regional pain syndrome is puzzling, and the cause isn’t clearly understood.

Women are more likely to be affected by complex regional pain syndrome than men are. Although complex regional pain syndrome is most common in people between the ages of 40 and 60, it can occur at any age. Treatment for complex regional pain syndrome is most effective when started early in the course of the syndrome.

Signs and symptoms

The main symptom of complex regional pain syndrome is intense pain, often described as “burning.” Additional signs and symptoms include:

• Skin sensitivity.
• Changes in skin temperature, color and texture. At times your skin may be sweaty; at other times it may be cold. Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in the affected area.
• Changes in hair and nail growth.
• Joint stiffness, swelling and damage.
• Muscle spasms, weakness and loss (atrophy).
• Decreased ability to move the affected body part.

Complex regional pain syndrome typically has three stages, though not everyone progresses through these phases at the same pace:

• Stage 1. Severe pain develops in one of your limbs. Swelling, sensitivity to touch or to cold, and skin changes, such as drying or thinning, begin to appear. This stage usually lasts one to three months.
• Stage 2. Changes to the color and texture of your skin become increasingly obvious, and the swelling spreads. You may begin to feel stiffness in your muscles and joints. This stage may last three to six months.
• Stage 3. Severe damage is evident, such as limited movement in your affected limb, irreversible skin damage, muscle atrophy and contractures in nearby digits.

Causes

Complex regional pain syndrome occurs in two types with similar signs and symptoms, but different causes:

• Type I. Previously known as reflex sympathetic dystrophy syndrome, this type occurs after an illness or injury that didn’t directly damage the nerves in your affected limb. About 90 percent of people withcomplex regional pain syndrome have type I.
• Type II. Once referred to as causalgia, this type follows a distinct nerve injury.

Many cases of complex regional pain syndrome occur after a forceful trauma to an arm or a leg, such as a gunshot wound or shrapnel blast. Other major and minor traumas — surgery, heart attacks, infections, fractures and even sprained ankles — also can lead to complex regional pain syndrome. It’s not well understood why these injuries sometimes trigger complex regional pain syndrome.

The syndrome was first described after the U.S. Civil War when soldiers continued to report severe pain after their wounds had healed. It was often referred to as “hot pain” during that period.

When to seek medical advice

If you experience constant, severe pain that affects a single limb and makes touching or movement of that limb seem intolerable, see your doctor to determine the cause. It’s important to treat complex regional pain syndrome early.

Screening and diagnosis

Your doctor may base a diagnosis of complex regional pain syndrome on:

• Review of your medical history. The onset of complex regional pain syndrome symptoms can often be traced back to an accident, illness or injury.
• Physical examination. An examination of your skin, muscles and joints may reveal information about the source of your tenderness and pain. There may be changes in the normal texture and color of your skin, and you may have problems with range of motion of one or more of your joints.
• Bone scan. A radioactive substance injected into one of your veins permits viewing of your bones with a special camera. This procedure may show increased circulation to the joints in the affected area.
• Sympathetic nervous system tests. These tests look for disturbances in your sympathetic nervous system. For example, thermography measures the skin temperature and blood flow of your affected and unaffected limbs. Other tests can measure the amount of sweat on both limbs. Dissimilar results can indicate complex regional pain syndrome.
• X-rays. Loss of minerals from your bones may show up on an X-ray in later stages of the disease.
• Magnetic resonance imaging (MRI). Images captured by an MRI device may show a number of tissue changes, such as skin thinning and muscle atrophy, that may help your doctor determine the stage of your disease.

Complications

If complex regional pain syndrome isn’t diagnosed and treated at an early stage, the disease may progress to more disabling signs and symptoms. If you avoid moving an arm or a leg because of pain, or if you have trouble moving a limb because of stiffness, your skin and muscles may begin wasting (atrophy). You may also experience tightening of your muscles. This may lead to a condition in which your hand and fingers or your foot and toes contract into a fixed position.

The illness may also spread from its source to elsewhere in your body in these patterns:

• Continuity type. The symptoms may migrate from the initial site of the pain — for example, from your hand to your shoulder, trunk and face — affecting a quadrant of your body.
• Mirror-image type. The symptoms may spread from one limb to the opposite limb.
• Independent type. Sometimes, the symptoms may leap to a distant part of your body.

Treatment

Dramatic improvement and even remission of complex regional pain syndrome is possible if treatment begins within a few months of your first symptoms. Treatment options include:

• Medications. Doctors use various medications to treat the symptoms of complex regional pain syndrome. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve), may ease pain and inflammation. In some cases, doctors may recommend prescription medications. For example, antidepressants such as amitriptyline and anticonvulsants such as gabapentin (Neurontin) are used to treat pain that originates from a damaged nerve (neuropathic pain). Corticosteroids, such as prednisone, may reduce inflammation.Your doctor may suggest bone-loss medications, such as alendronate (Fosamax) and calcitonin (Miacalcin). Opioid medications may be another option. Taken in appropriate doses, they may provide acceptable control of pain. However, they may not be appropriate if you have a history of substance abuse or lung disease.

  Some pain medications, such as COX-2 inhibitors (Celebrex), may increase your risk of heart attack and stroke. It’s wise to discuss your individual risk profile with your doctor.

• Applying heat and cold. Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.
• Capsaicin. This cream, made from the seeds of hot chili peppers, may relieve pain caused by nerve damage in early-stage complex regional pain syndrome. Your doctor may recommend applying the cream to the affected area several times daily. Capsaicin cream can be very irritating if rubbed on nonaffected parts of your body. Follow the application instructions carefully. You should be able to tell within a week whether the treatment is effective and tolerable.
• Physical therapy. Gentle, guided exercising of the affected limbs may improve range of motion and strength. The earlier the disease is diagnosed, the more effective exercises may be.
• Sympathetic nerve-blocking medication. Injection of an anesthetic to block pain fibers in your affected nerves may relieve pain in some people.
• Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.
• Biofeedback. In some cases, learning biofeedback techniques may help. In biofeedback, you learn to become more aware of your body so that you can relax your body and relieve pain.
• Spinal cord stimulation. Your doctor inserts tiny electrodes along your spinal cord. A small electrical current delivered to the spinal cord sometimes results in pain relief.

Coping skills

Living with a chronic, painful condition can be challenging, especially when — as is often the case with complex regional pain syndrome — your friends and family don’t believe you could be feeling as much pain as you describe. Share information from reliable sources about complex regional pain syndrome with those close to you to help them understand what you’re experiencing.

Take care of your physical and mental health by following these suggestions:

• Maintain normal daily activities as best you can.
• Pace yourself and be sure to get the rest that you need.
• Stay connected with friends and family.
• Continue to pursue hobbies that you enjoy and are able to do.

If complex regional pain syndrome makes it difficult for you to do things you enjoy, ask your doctor about ways to get around the obstacles.

Keep in mind that your physical health can directly affect your mental health. Denial, anger and frustration are common with chronic illnesses.

At times, you may need more tools to deal with your emotions. Professionals such as therapists or behavioral psychologists may be able to help you put things in perspective. They can also teach you coping skills that may help you, including relaxation techniques.

Sometimes, joining a support group, where you can share experiences and feelings with other people, is a good approach. Ask your doctor what support groups are available in your community.

Introduction
GERD — gastroesophageal reflux disease — is more than just chronic heartburn. Although heartburn is the most common symptom of this disease, GERD is a condition in which stomach acid or, occasionally, bile flows back (refluxes) into your food pipe (esophagus). The constant backwash or acid reflux can irritate the lining of your esophagus and cause inflammation. Such irritation can lead to complications such as narrowing of the esophagus, ulcers and even a slightly increased risk of esophageal cancer.

Most people can manage the discomfort of heartburn with lifestyle modifications and over-the-counter medications. But if you have GERD, these remedies may offer only temporary or partial relief. If you have GERD, you may need newer, more potent medications, possibly even surgery, to reduce symptoms.

Signs and symptoms
Common signs and symptoms of GERD include:

Heartburn — burning sensation in your chest, sometimes spreading to the throat, along with a sour taste in your mouth.
Chest pain, especially at night while lying down
Difficulty swallowing (dysphagia)
Coughing, wheezing, asthma, hoarseness or sore throat
Regurgitation of food or sour liquid
Causes
When you swallow, the lower esophageal sphincter — a circular band of muscle around the bottom part of your esophagus — relaxes to allow food and liquid to flow down into your stomach. Then it closes again.

However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your esophagus, causing frequent heartburn and disrupting your daily life. The acid backup is worse when you bend over or lie down.

This constant backwash of acid can irritate the lining of your esophagus, causing it to become inflamed (esophagitis). Over time, the inflammation can erode the esophagus, producing bleeding, or narrow the esophagus, causing difficulty swallowing or even breathing problems. When there’s evidence of esophageal irritation or inflammation, you have GERD. However, many people with GERD will have a normal-appearing esophagus despite symptoms.

GERD may be related to other conditions such as hiatal hernia. In this condition, also called diaphragmatic hernia, part of your stomach protrudes into your lower chest. If the protrusion is large, a hiatal hernia can worsen heartburn by further weakening the lower esophageal sphincter muscle.

Some factors that can make GERD worse include:

Certain foods, such as fatty foods, spicy foods, chocolate, caffeine, onions, tomato sauce, carbonated beverages and mint
Alcohol
Large meals
Lying down soon after eating
Certain medications, including sedatives, tranquilizers and calcium channel blockers for high blood pressure
Cigarette smoking
Risk factors
Conditions that cause difficulty with digestion can increase the risk of GERD. These include:

Obesity. Excess weight puts extra pressure on your stomach and diaphragm — the large muscle that separates your chest and abdomen — forcing open the lower esophageal sphincter and allowing stomach acids to back up into your esophagus. Eating very large meals or meals high in fat may cause similar effects.
Hiatal hernia. In this condition, also called diaphragmatic hernia, part of your stomach protrudes into your lower chest. If the protrusion is large, a hiatal hernia can worsen heartburn by further weakening the lower esophageal sphincter muscle.
Pregnancy. Pregnancy results in greater pressure on the stomach and a higher production of the hormone progesterone. This hormone relaxes many of your muscles, including the lower esophageal sphincter.
Asthma. Doctors aren’t certain of the exact relationship between asthma and heartburn. It may be that coughing and difficulty exhaling lead to pressure changes in your chest and abdomen, triggering regurgitation of stomach acid into your esophagus. Some asthma medications that widen (dilate) airways may also relax the lower esophageal sphincter and allow reflux. Or it’s possible that the acid reflux that causes heartburn may worsen asthma symptoms. For example, you may inhale small amounts of the digestive juices from your esophagus and pharynx, damaging lung airways.
Diabetes. One of the many complications of diabetes is gastroparesis, a disorder in which your stomach takes too long to empty. If left in your stomach too long, stomach contents can regurgitate into your esophagus and cause heartburn.
Peptic ulcer. An open sore or scar near the valve (pylorus) in the stomach that controls the flow of food into the small intestine can keep this valve from working properly or can obstruct the release of food from the stomach. Food doesn’t empty from your stomach as fast as it should, causing stomach acid to build up and back up into your esophagus.
Delayed stomach emptying. In addition to diabetes or an ulcer, abnormal nerve or muscle functions can delay emptying of your stomach, causing acid backup into the esophagus.
Connective tissue disorders. Diseases such as scleroderma that cause muscular tissue to thicken and swell can keep digestive muscles from relaxing and contracting as they should, allowing acid reflux.
Zollinger-Ellison syndrome. One of the complications of this rare disorder is that your stomach produces extremely large amounts of acid, increasing the risk of acid reflux.
When to seek medical advice
Most problems with heartburn are short-term and mild. But if you have severe or frequent discomfort, or you experience any of the other symptoms of GERD for a while, you may be developing complications that need more intensive medical treatment and prescription medications. Talk to your doctor if you have:

Heartburn several times a week
Heartburn that returns soon after your antacid wears off
Heartburn that wakes you up at night
Difficulty swallowing
You may need further medical care, possibly even surgery, if you experience any of these:

Symptoms that persist even though you’re taking prescription medications
Difficulty swallowing
Regurgitated blood
Stool that’s black
Weight loss
Screening and diagnosis
Usually a description of your symptoms will be all your doctor needs to establish the diagnosis of heartburn. However, if your symptoms are particularly severe or don’t respond to treatment, you may need to undergo other tests to check for GERD and other conditions:

Barium X-ray. This procedure requires you to drink a chalky liquid that coats and fills the hollows of your digestive tract. The coating allows your doctor to see a silhouette of the shape and condition of your esophagus, stomach and upper intestine (duodenum). X-rays can also reveal whether a hiatal hernia may be contributing to your heartburn. They can also reveal an esophageal narrowing or stricture, or a growth, which may cause difficulty swallowing.
Endoscopy. A more direct test for diagnosing the cause of heartburn is esophagogastroduodenoscopy (EGD). In this test your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. The endoscope allows your doctor to see if you have an ulcerated or inflamed esophagus (esophagitis) or stomach (gastritis). It can also reveal a peptic ulcer. During an EGD, your doctor can take tissue samples to test for Barrett’s esophagus — a condition in which precancerous changes occur in cells in your esophagus — or esophageal cancer, two potential complications of severe heartburn. Your doctor also may take biopsies of the stomach that may reveal the presence of a bacterium that may cause peptic ulcers. Some of the reasons you may need an endoscopy are if medications aren’t working for you, you have had GERD symptoms for a long time, you experience difficulty swallowing, weight loss, regurgitation of blood or black material, or your doctor is not sure whether you have GERD. Although endoscopy results often appear normal despite GERD, sometimes endoscopy can reveal inflammation, stricture, Barrett’s esophagus or cancer.
Ambulatory acid (pH) probe tests. These tests use an acid-measuring (pH) probe to identify when, and for how long, stomach acid regurgitates into your esophagus. This information can help your doctor determine how best to treat your condition. In the standard tube test, a nurse or technician sprays your throat with a numbing medication while you’re seated. Then a thin, flexible tube (catheter) is threaded through your nose into your esophagus to insert the probe. The probe is positioned just above the lower esophageal sphincter. A second probe may be placed in your upper esophagus. Attached to the other end of the catheter is a small computer that you wear around your waist or with a strap over your shoulder during the test. It records acid measurements. After the probe is in place, you go about your business and then come back one or two days later to have the device removed. Another ambulatory test called a Bravo pH probe may be more comfortable than the standard test, because it eliminates the need for a tube in your nose. In the Bravo test, the probe is attached to the lower portion of your esophagus during endoscopy. The probe transmits a signal to a small computer that you wear around your waist for about two days, and then the probe falls off to be passed in your stool. Another benefit of the Bravo test is that you can shower and sleep more comfortably than with the standard test. Generally, if you have symptoms of GERD your doctor will likely first treat you with medication. If the medication doesn’t work or you have side effects and can’t tolerate it, your doctor may order an ambulatory acid (pH) probe test.
Esophageal impedance. Rather than measuring acid, this test can measure whether gas or liquids reflux back into your esophagus. It’s helpful for people who have regurgitation or reflux of materials in the esophagus that aren’t acidic and wouldn’t be detected by a pH probe. The test works by placing a catheter through your nose and into your esophagus, similar to a standard pH probe tube test. However, because the test is new, its role in helping people with GERD hasn’t been clearly defined.
Complications
In addition to irritation and inflammation of your esophagus (esophagitis), chronic reflux of stomach acid into your esophagus can lead to one or more of the following conditions if left untreated:

Esophageal narrowing (stricture). Strictures occur in some people with GERD. Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing large chunks of food to get caught up in the narrowing, and can interfere with swallowing.
Esophageal ulcer. Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult.
Barrett’s esophagus. This is a serious, though uncommon, complication of GERD. In Barrett’s esophagus, the color and composition of the tissue lining the lower esophagus change. Instead of pink, the tissue turns a salmon color. Under a microscope, the tissue resembles that of the small intestine. This cellular change is called metaplasia. Metaplasia is brought on by repeated and long-term exposure to stomach acid and is associated with an increased risk of esophageal cancer. The risk of cancer is low, but you’ll need regular endoscopies to look for early warning signs of cancer if you’re diagnosed with Barrett’s esophagus.
Treatment
Whether you have mild, moderate or severe heartburn, many treatment options are available. The most common treatments involve medications, but surgical and other procedures also are available.

Over-the-counter remedies
If you experience only occasional, mild heartburn, you may get relief from an over-the-counter (OTC) medication and self-care measures. OTC remedies include:

Antacids. Antacids, such as Maalox, Mylanta, Gelusil, Rolaids and Tums, neutralize stomach acid and can provide quick relief. But antacids alone won’t heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects such as diarrhea or constipation. A liquid antacid will coat your esophagus and help reduce stomach acid.
H-2-receptor blockers. Over-the-counter H-2-receptor blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac 75), are available at half the strength of their prescription versions. Instead of neutralizing the acid, these medications reduce the production of acid. They don’t act as quickly as antacids, but they provide longer relief. Take these medications before a meal that you think may cause heartburn because it takes them about 30 minutes to work. They’re also effective in reducing reflux at night if taken at bedtime. H-2-receptor blockers can cause infrequent side effects, including bowel changes, dry mouth, dizziness or drowsiness. In rare instances they can also react dangerously with other medications.
Proton pump inhibitors. These medications block acid production and allow time for damaged esophageal tissue to heal. Omeprazole (Prilosec) was previously available only by prescription, but now is available in an over-the-counter form for short-term treatment of heartburn. Do not use OTC omeprazole long term unless prescribed by your doctor. See your doctor to make sure that you don’t have any complications of GERD.
Prescription-strength medications
If you have frequent and persistent heartburn leading to an inflamed esophagus, you’ll likely need prescription-strength medication. It’s important that you take these medications correctly, and generally 30 minutes before a meal. Prescription medications can help reduce and eliminate GERD symptoms, as well as help heal an inflamed esophagus — the result of continual exposure to stomach acid. The main types of prescription drugs are:

Prescription-strength H-2-receptor blockers. These significantly reduce acid production and have few side effects. They include prescription-strength Axid, Pepcid, Tagamet and Zantac.
Prescription-strength proton pump inhibitors. These are long-acting and are the most effective medications for suppressing acid production. They’re safe and have few side effects for long-term treatment. To prevent possible side effects, such as diarrhea or headaches, your doctor will likely prescribe the lowest effective dose. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) and rabeprazole (Aciphex).
Prokinetic agents. These don’t reduce acid production. Instead, they help your stomach empty more rapidly and may help tighten the valve between the stomach and the esophagus. Because the prokinetic agents thus far sometimes cause serious side effects, researchers are working to develop safer versions.
Surgical and other procedures
Because of the effectiveness of medications, surgery for GERD is uncommon. However, it may be an option if you can’t tolerate the medications, you can’t afford their long-term use or your doctor determines that the medications are ineffective. Your doctor may also recommend surgery if you have any of these complications:

Large hiatal hernia
Severe esophagitis, especially with bleeding
Recurrent narrowing (stricture) of the esophagus
Severe pulmonary problems, such as bronchitis or pneumonia, due to acid reflux
GERD that is not controllable by medication
Before 1991, a procedure called open Nissen fundoplication was the surgery of choice for severe GERD. Today, doctors are able to perform the same surgery with similar success laparoscopically — through a few small abdominal incisions, instead of one large one. The advantages of laparoscopic surgery are a shorter recovery time and less discomfort.

Nissen fundoplication involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. During laparoscopic surgery, a surgeon makes three or four small incisions in the abdomen and inserts instruments, including a flexible tube with a tiny camera, through the incisions.

People who benefit most from a Nissen fundoplication are those who gained relief from medications. If you have minimal or no relief from medications, your doctor must be certain that you have GERD before recommending surgery, which may mean additional testing. Most people who undergo Nissen fundoplication remain free of GERD symptoms for at least two years. For the majority of people, this benefit extends to five years or more. You may still require medications for GERD, but your GERD will likely be easier to control.

Other surgical procedures include Toupet fundoplication, Hill repair and the Belsey Mark IV operation. All involve restructuring the lower esophageal sphincter to improve its strength and ability to prevent reflux. These surgeries are done less often, and their success is often dependent on the skill of the surgeon.

Complications from surgery generally are mild, but may include difficulty swallowing, bloating and diarrhea. These complications generally go away within one year.

Newer, less-invasive procedures
Your doctor may suggest a procedure for tightening the lower esophageal sphincter. These procedures generally take less time to perform, they don’t require any incisions, and you can go home the same day. The procedures are performed endoscopically through a long, flexible tube that’s inserted into your mouth and down your esophagus. These procedures are recommended if you have a hiatal hernia or Barrett’s esophagus.

EndoCinch endoluminal gastroplication. This procedure uses a tool that’s like a miniature sewing machine. It places pairs of stitches (sutures) in the stomach near the weakened sphincter. The suturing material is then tied together, creating barriers (plications) to prevent stomach acid from washing into your esophagus. The barriers are located at and just below the junction of the esophagus and stomach. The procedure may cause a sore throat or chest pain. The long-term effectiveness of the procedure is still unknown.
Stretta procedure. This approach uses controlled radiofrequency energy to heat and melt (coagulate) tissues within the portion of the esophagus that contains the malfunctioning valve and at the junction of the esophagus and upper stomach. The procedure appears to work by creating scar tissue and altering the sensory nerves that respond to refluxed acid. The procedure may cause a sore throat or chest pain. The long-term effectiveness of the procedure is still unknown.
Self-care
You may eliminate or reduce the frequency of heartburn by making the following lifestyle changes:

Control your weight. Being overweight is a major risk factor for heartburn and GERD. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus.
Eat smaller meals. This reduces pressure on the lower esophageal sphincter, helping to prevent the valve from opening and acid from washing back into your esophagus.
Loosen your belt. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
Eliminate heartburn triggers. Everyone has specific triggers. Common triggers such as fatty or fried foods, alcohol, chocolate, peppermint, garlic, onion, caffeine and nicotine may make heartburn worse.
Avoid stooping or bending. Tying your shoes is OK. Bending over for longer periods to weed your garden isn’t, especially soon after eating.
Don’t lie down after a meal. Wait at least three to four hours after eating before going to bed, and don’t lie down right after eating.
Raise the head of your bed. An elevation of about six to nine inches puts gravity to work for you. You can do this by placing wooden or cement blocks under the feet of your bed at the head end. If it’s not possible to elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head only by using pillows is not a good alternative.
Don’t smoke. Smoking may increase stomach acid. The swallowing of air during smoking may also aggravate belching and acid reflux. In addition, smoking and alcohol increase your risk of esophageal cancer.
Complementary and alternative medicine
Several home remedies exist for treating GERD, but they provide only temporary relief. They include drinking baking soda (sodium bicarbonate) added to water or drinking other fluids such as baking soda mixed with cream of tartar and water.

Although these liquids create temporary relief by neutralizing, washing away or buffering acids, eventually they aggravate the situation by adding gas and fluid to your stomach, increasing pressure and causing more acid reflux. Further, adding more sodium to your diet may increase your blood pressure and add stress to your heart, and excessive bicarbonate ingestion can alter the acid-base balance in your body.

Introduction

Vesicoureteral reflux is the abnormal flow of urine from your bladder back up the tubes (ureters) from your kidneys. Normally, urine flows only down from your kidneys to your bladder.

Most commonly a condition of infancy and childhood, vesicoureteral reflux increases the risk of urinary tract infections. Untreated, it can lead to kidney damage.

There are two types of vesicoureteral reflux — primary and secondary. Children with primary vesicoureteral reflux are born with a defect in the valve that normally prevents urine from flowing backward from the bladder into the ureters. Secondary vesicoureteral reflux is due to a blockage, often caused by infection, in the urinary tract.

Children may outgrow primary vesicoureteral reflux. Treatment, which includes medication or surgery, is aimed at preventing kidney damage.

Signs and symptoms

A urinary tract infection (UTI) is the most common indication of vesicoureteral reflux. Not everyone with a UTI develops recognizable signs and symptoms, but most people have some. These can include:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• Passing frequent, small amounts of urine
• Blood in the urine (hematuria) or cloudy, strong-smelling urine
• Fever
• Abdominal or flank pain

A UTI may be difficult to diagnose in children, who may have nonspecific signs and symptoms. Signs and symptoms in infants with a UTI may include:

• Lack of normal growth (failure to thrive)
• Vomiting and diarrhea
• Lack of appetite
• Lethargy

As your child gets older, untreated vesicoureteral reflux can lead to other signs and symptoms, including:

• Bed-wetting
• High blood pressure
• Protein in urine
• Kidney failure

Another indication of vesicoureteral reflux, which may be detected by sonogram of the fetus in the womb, is swelling of the urine-collecting structures of one or both kidneys (hydronephrosis), caused by the backup of urine into the kidneys.

Causes

Your urinary system comprises your kidneys, ureters, bladder and urethra. All play a role in removing waste from your body.

The kidneys, a pair of bean-shaped organs at the back of your upper abdomen, filter waste, water and electrolytes — minerals such as sodium, calcium and potassium that help maintain the balance of fluids in your body — from your blood. Tubes called ureters carry urine from your kidneys down to your bladder, where it is stored until it exits the body through the urethra during urination.

Vesicoureteral reflux can develop in two forms, primary and secondary:

• Primary vesicoureteral reflux. The cause of this more common form is a defect that’s present before birth (congenital). The defect is in the valve between the bladder and a ureter that normally closes to prevent urine from flowing backward. As the child grows, the ureters lengthen, which may improve valve function and eventually resolve the reflux. This type of vesicoureteral reflux tends to run in families, which indicates that it may be genetic, but the exact cause of the defect is unknown.
• Secondary vesicoureteral reflux. The cause of this form is a blockage in the urinary system. The blockage most commonly results from a UTI, which may cause swelling of a ureter.

Risk factors

• Race. White children are three times as likely to have vesicoureteral reflux as black children are.
• Sex. Girls are twice as likely to have the condition as boys are.
• Age. Infants and children up to age 2 are more likely to have vesicoureteral reflux than older children are.
• Family history. Primary vesicoureteral reflux tends to run in families. Children whose parents had the condition are at higher risk of developing it. Siblings of children who have the condition also are at higher risk, so your doctor may recommend screening for the siblings of a child with primary vesicoureteral reflux.

When to seek medical advice

Contact your doctor promptly if your child develops any of the signs or symptoms of a UTI, such as:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• Abdominal or flank pain

The presence of fever and flank pain indicates that the infection likely involves the kidneys. If your infant is lethargic, has vomiting or diarrhea, or refuses to eat, see your doctor.

Screening and diagnosis

Laboratory analysis of urine (urinalysis), sometimes followed by a urine culture, can reveal whether your child has a UTI. Other tests are necessary to determine the presence of vesicoureteral reflux. They may include:

• Kidney and bladder ultrasound. Also called sonography, this imaging method uses high-frequency sound waves to produce images of the kidney and bladder. This same technology, which often is used during pregnancy to monitor fetal development, may also reveal swollen kidneys in the fetus, an indication of primary vesicoureteral reflux.
• Voiding cystourethrogram (VCUG). This test uses X-rays of the bladder when it’s full and when it’s emptying to detect any abnormalities. A thin, flexible tube (catheter) is inserted through your urethra and into your bladder while you lie on your back on an X-ray table. After contrast dye is injected into your bladder through the catheter, your bladder is X-rayed in various positions. Then the catheter is removed so that you can urinate, and more X-rays are taken of your bladder and urethra during urination to see whether the urinary tract is functioning correctly.Risks associated with this test include discomfort, both from the catheter and from having a full bladder, and possibly, an allergic reaction to the dye in the form of bladder spasms.
• Nuclear scans. This test, known as radionuclide cystogram, uses a procedure similar to that used for VCUG, except that instead of dye being injected into your bladder through the catheter, this test uses a radioactive material (radioisotope). The scanner detects the radioactivity and shows whether the urinary tract is functioning correctly. Risks include discomfort from the catheter and discomfort during urination. Urine may be slightly pink urine for a day or two after the test.

Grading the condition
Vesicoureteral reflux can be graded according to severity. The most common grading system grades from the mildest condition, in which urine backs up only to the ureter (grade I), to the most severe, which involves severe swelling (hydronephrosis) and twisting of the ureter (grade V).

Complications

Kidney damage is the primary concern with vesicoureteral reflux. The higher the grade, the more serious the complications are likely to be. Complications may include:

• Kidney (renal) scarring. Untreated UTIs can lead to scarring, also known as reflux nephropathy, which is permanent damage to kidney tissue. Pressure is generally higher in your bladder than it is in your kidneys, so the backup of urine exposes your kidneys to the higher pressure of your bladder. Over time, the higher pressure may cause scarring. Extensive scarring may lead to high blood pressure and kidney failure.
• High blood pressure (hypertension). Because your kidneys remove waste from your bloodstream, damage to your kidneys and the resultant buildup of wastes can raise your blood pressure.
• Acute kidney failure. Loss of function in the filtering part of the kidney may cause waste products to accumulate rapidly. This condition may require emergency dialysis, an artificial means of removing extra fluids and waste from your blood, typically by an artificial kidney machine (dialyzer).
• Chronic kidney failure. In this extremely serious complication, the kidneys gradually lose function. Kidney function at less than 15 percent of normal capacity indicates end-stage kidney disease, which usually requires dialysis or a kidney transplant to sustain life.

Treatment

Treatment of vesicoureteral reflux depends on the severity of the condition. Children with mild cases of primary vesicoureteral reflux may eventually outgrow the disorder. In this case, your doctor will likely recommend a wait-and-see approach. During this time, it will be important for you to be watchful for potential UTIs and to seek prompt treatment.

There are two types of treatment for the condition: medication and surgery. Using medication is more common, with surgery usually reserved for those children for whom antibiotics aren’t successful. The goal of treatment is to prevent kidney damage.

Medications
UTIs require prompt treatment with antibiotics to keep the infection from moving to the kidneys. Doctors also use antibiotics to prevent UTIs, usually at about half the dose for treating an infection.

Commonly used antibiotics include trimethoprim-sulfamethoxazole (Bactrim, Septra), trimethoprim (Proloprim) and nitrofurantoin (Furadantin, Macrodantin). Possible side effects of long-term use of these drugs include:

• Nausea and vomiting
• Abdominal pain
• Increased antibiotic resistance, in which the condition no longer responds to antibiotics and becomes more difficult to treat

A child being treated with medication will need to be monitored for as long as he or she is taking antibiotics. This includes periodic physical exams and urine tests to detect breakthrough infections — UTIs that occur despite the antibiotic treatment — and occasional X-rays of the bladder and kidneys to determine if and when your child outgrows vesicoureteral reflux.

Surgery
For children with primary vesicoureteral reflux who don’t outgrow the condition, surgery repairs the defect in the valve between the bladder and each affected ureter that keeps it from closing and preventing urine from flowing backward. There are two methods of surgical repair:

• Open surgery. Performed using general anesthesia, this surgery requires an incision in the lower abdomen through which the surgeon repairs the malformation that’s causing the problem. This type of surgery usually requires a few days’ stay in the hospital, during which a catheter is kept in place to drain your child’s bladder. Risks include infection, blood clots and bleeding.
• Endoscopic surgery. In this procedure, your doctor inserts a lighted tube (cystoscope) through the urethra to see inside your child’s bladder, then injects a bulking agent around the opening of the affected ureter to try to strengthen the valve’s ability to close properly. This method is minimally invasive compared with open surgery and presents fewer risks. This procedure also requires general anesthesia, but generally can be performed as outpatient surgery.

Self-care

UTIs, which are so common to vesicoureteral reflux, can be painful. But you can take steps to ease your child’s discomfort until antibiotics clear the infection. They include:

• Encourage your child to drink fluids, particularly water. Drinking water dilutes urine and may help flush out bacteria. Avoid citrus juices and soft drinks containing citrus juices and caffeine until your child’s infection has cleared. They can irritate the bladder and tend to aggravate the frequent or urgent need to urinate.
• Use a heating pad. Sometimes a heating pad placed over your child’s abdomen can help minimize feelings of bladder pressure or pain. Keep the heat low and monitor your child closely when he or she has a heating pad in place to prevent burns.

Introduction

Pancreatic cancer is one of the most serious of cancers. It develops when cancerous cells form in the tissues of your pancreas — a large organ that lies horizontally behind the lower part of your stomach. Your pancreas secretes enzymes that aid digestion and hormones that help regulate the metabolism of carbohydrates.

Pancreatic cancer spreads rapidly and is seldom detected in its early stages, which is a major reason why it’s a leading cause of cancer death. Signs and symptoms may not appear until the disease is quite advanced. By that time, the cancer is likely to have spread to other parts of the body and surgical removal is no longer possible.

For years, little was known about pancreatic cancer. But researchers are beginning to understand the genetic basis of the disease — knowledge that may eventually lead to new and better treatments. Just as important, you may be able to reduce your risk of pancreatic cancer with some lifestyle changes.

Signs and symptoms

Signs and symptoms of pancreatic cancer often don’t occur until the disease is advanced. When symptoms do appear, they may include:

• Upper abdominal pain that may radiate to your middle or upper back. Pain is a common symptom of advanced pancreatic cancer. Abdominal pain occurs when a tumor presses on surrounding organs and nerves. Pain may be constant or intermittent and is often worse after you eat or when you lie down. Because many conditions other than cancer can cause abdominal pain, be sure to discuss your symptoms carefully with your doctor.
• Loss of appetite and unintentional weight loss. Unintended weight loss is a common sign of pancreatic cancer. Weight loss occurs in most types of cancer because cancerous (malignant) cells deprive healthy cells of nutrients, and this is especially true in pancreatic cancer.
• Yellowing of your skin and the whites of your eyes (jaundice). About half of people with pancreatic cancer develop jaundice, which occurs when bilirubin, a breakdown product of worn-out blood cells, accumulates in your blood. Normally, bilirubin is eliminated in bile, a fluid produced in your liver. But if a pancreatic tumor blocks the flow of bile, excess pigment from bilirubin may turn your skin and the whites of your eyes yellow. In addition, your urine may be dark brown and your stools white or clay-colored. Although jaundice is a common sign of pancreatic cancer, it’s more likely to result from other conditions, such as gallstones or hepatitis.
• Itching. In the later stages of pancreatic cancer, you may develop severe itching when high levels of bile acids, another component of bile, accumulate in your skin.
• Nausea and vomiting. In advanced cases of pancreatic cancer, the tumor may block a portion of your digestive tract, usually the upper portion of your small intestine (duodenum), causing nausea and vomiting.
• Digestive problems. When cancer prevents pancreatic enzymes from being released into your intestine, you’re likely to have a hard time digesting foods — especially those high in fat. Eventually, this may lead to significant weight loss — as much as 25 pounds or more — and malnutrition.

Causes

Your pancreas is about 6 inches long and looks something like a pear lying on its side. The wider end (head) is located near the center of your abdomen next to the upper part of your small intestine (duodenum). The main part (body) of the pancreas stretches behind your stomach, and the narrow end (tail) is on your left side, next to your spleen.

A part of your digestive system, your pancreas performs two essential functions:

• It produces digestive juices and enzymes that help break down proteins, carbohydrates and fats so the food you eat can be digested in your small intestine.
• It secretes the hormones insulin and glucagon that regulate the way your body metabolizes sugar (glucose).

Most of your pancreas is composed of cells that produce digestive enzymes and juices. Pancreatic juices flow into the main pancreatic duct, which leads to your small intestine (duodenum). The pancreatic duct joins up with the tube leading from your gallbladder to form the common bile duct, which then empties into the small intestine. Your pancreas also contains small “islands” of cells that secrete the hormones insulin and glucagon, along with somatostatin.

Types of pancreatic cancer
Most pancreatic tumors originate in the duct cells or in the cells that produce digestive enzymes (acinar cells). Called adenocarcinomas, these tumors account for nearly 95 percent of pancreatic cancers.

Tumors that begin in the islet cells (endocrine tumors) are much less common. When they do occur, they may cause the affected cells to produce too much hormone. For example, tumors in glucagon cells (glucagonomas) might cause excess amounts of glucagon to be secreted, while tumors in insulin cells (insulinomas) may lead to an overproduction of insulin.

Tumors can also develop in the ampulla of Vater — the place where your bile and pancreatic ducts empty into your small intestine. Called ampullary cancers, these tumors often block the bile duct, leading to jaundice. Because even a small tumor can obstruct the bile duct, signs and symptoms of ampullary cancer usually appear earlier than do symptoms of other pancreatic cancers.

Why pancreatic cancer occurs
Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor — a mass of malignant cells.

Researchers don’t know exactly what damages DNA in the vast majority of cases of pancreatic cancer. But it is known that a small percentage of people develop the disease as a result of a genetic predisposition. These people who have a close relative, such as a parent or sibling, with pancreatic cancer have a higher risk of developing pancreatic cancer themselves.

In addition, a number of genetic diseases have been associated with an increased risk of pancreatic cancer, including familial adenomatous polyposis, nonpolyposis colon cancer, familial breast cancer associated with the BRCA2 gene, hereditary pancreatitis, and familial atypical multiple mole-melanoma syndrome — a serious type of skin cancer. This means that people who have a hereditary predisposition to develop these cancers are also more likely to develop pancreatic cancer.

Yet only about 10 percent of pancreatic cancers result from an inherited tendency. A greater number are caused by environmental or lifestyle factors, such as smoking, diet and chemical exposure.

Risk factors

The vast majority of pancreatic cancers occur in people older than 65. Other important risk factors include:

• Race. Black men and women have a higher risk of pancreatic cancer.
• Sex. More men than women develop pancreatic cancer.
• Cigarette smoking. If you smoke, you’re two to three times more likely to develop pancreatic cancer than nonsmokers are. This is probably the greatest known risk factor for pancreatic cancer, with smoking associated with almost one in three cases of pancreatic cancer.
• Abnormal glucose metabolism. Having diabetes may increase your risk of pancreatic cancer. Insulin resistance or high insulin levels may also be risk factors for pancreatic cancer.
• Hereditary pancreatitis. Your chances of developing pancreatic cancer increase if you have hereditary chronic pancreatitis. Hereditary pancreatitis (HP) is a rare genetic condition marked by recurrent attacks of pancreatitis — a painful inflammation of your pancreas.
• Excess weight. People who are very overweight or obese may have a greater risk of developing pancreatic cancer than do people of normal weight.
• Diet. A diet high in animal fat and low in fruits and vegetables may increase your risk of pancreatic cancer.
• Chemical exposure. People who work with petroleum compounds, including gasoline and other chemicals, have a higher incidence of pancreatic cancer than people not exposed to these chemicals.

When to seek medical advice

See your doctor if you experience an unexplained weight loss, abdominal pain or jaundice. Many problems other than cancer may cause similar signs and symptoms, so your doctor will check for these conditions as well as for pancreatic cancer. If cancer is present, early diagnosis and treatment offer the best chance of recovery.

Screening and diagnosis

Detecting pancreatic cancer in its early stages is difficult. Signs and symptoms usually don’t appear until the cancer is large or has spread (metastasized) to other tissues. And because your pancreas is relatively hidden — tucked behind your stomach and inside a loop of your small intestine — small tumors can’t be seen or felt during routine exams.

For this reason, and because pancreatic cancer spreads so quickly, researchers have focused on finding a reliable screening test. At one time, scientists thought a substance called CA 19-9 was the answer. CA 19-9 is produced by pancreatic cancer cells and can be detected by a blood test. But by the time blood levels are high enough to be measured, the cancer is no longer in its early stages. Currently there is no effective screening test for pancreatic cancer.

If your doctor suspects pancreatic cancer, you may have one or more of the following tests to diagnose the cancer:

• Ultrasound imaging. In this test, a device called a transducer is placed on your upper abdomen. High-frequency sound waves from the transducer reflect off your abdominal tissues and are translated by a computer into moving images of your internal organs, including your pancreas. Ultrasound tests are safe, noninvasive and relatively brief — a typical test takes less than an hour.
• Computerized tomography (CT) scan. This imaging test allows your doctor to visualize your organs, including your pancreas, in two-dimensional slices. Split-second computer processing creates these images as a series of very thin X-ray beams pass through your body. Sometimes you may have a dye (contrast medium) injected into a vein before the test. The clearer images produced with the dye make it easier to distinguish a tumor from normal tissue. A CT scan exposes you to more radiation than do conventional X-rays, but in most cases, the benefits of the test outweigh the risks.
• Magnetic resonance imaging (MRI). Instead of X-rays, this test uses a powerful magnetic field and radio waves to create images of your pancreas. During the test, you’re placed in a cylindrical tube that can seem confining to some people. The machine also makes a loud thumping noise you might find disturbing. In most cases you’ll be given headphones for the noise.
• Endoscopic retrograde cholangiopancreatiography (ERCP). In this procedure, a thin, flexible tube (endoscope) is gently passed down your throat, through your stomach and into the upper part of your small intestine. Air is used to inflate your intestinal tract so your doctor can more easily see the openings of your pancreatic and bile ducts. The bile ducts are thin tubes that carry bile, a fluid produced in your liver that helps digest fats. These ducts are often the site of pancreatic tumors. A dye is then injected into the ducts through a small hollow tube (catheter) that’s passed through the endoscope. Finally, X-rays are taken of the ducts. Your throat may be sore for a time after the procedure, and you may feel bloated from the air introduced into your intestine.
• Endoscopic ultrasound (EUS). In this test, an ultrasound device is passed through an endoscope into your stomach. The device directs sound waves to your pancreas. A computer then translates the sound waves into close-up images of your pancreas and your bile and pancreatic ducts. The images are superior to those produced by standard ultrasound and are particularly useful for detecting small pancreatic tumors.
• Percutaneous transhepatic cholangiography (PTC). In this test, your doctor carefully inserts a thin needle into your liver while you lie on a movable X-ray table. A dye is then injected into the bile ducts in your liver, and a special X-ray machine (fluoroscope) tracks the dye as it moves through the ducts. Any obstructions should show up on the X-ray. The table is rotated several times during the procedure so you can assume a variety of positions. During the test, you may have a feeling of pressure or fullness, or have slight discomfort in the right side of your back.
• Biopsy. In this procedure, a small sample of tissue is removed and examined for malignant cells under a microscope. It’s the only way to make a definitive diagnosis of cancer. Biopsies of the pancreas and bile ducts can be performed in several ways. If you have a mass that can be reached with a needle, your doctor may choose to perform a fine-needle aspiration (FNA) — a procedure in which a very thin needle is inserted through your skin and into your pancreas. An ultrasound or CT scan is often used to guide the needle’s placement. When the needle has reached the tumor, cells are withdrawn and sent to a lab for further study. Tissue samples can also be removed during ERCP or EUS. Sometimes, in a procedure similar to ERCP, your surgeon uses an endoscope to pass a catheter into your bile duct where it empties into your small intestine. But instead of injecting dye, your surgeon uses a small brush introduced through the catheter to scrape cells and bits of tissue from the lining of the duct.
• Laparoscopy. This procedure uses a small, lighted instrument (laparoscope) to view your pancreas and surrounding tissue. The instrument is attached to a television camera and inserted through a small incision in your abdomen. The camera allows your surgeon to clearly see what’s happening inside you. During laparoscopy, your surgeon can take tissue samples to help confirm a diagnosis of cancer. Laparoscopy may also be used to determine how far cancer has spread. Risks include bleeding and infection and a slight chance of injury to your abdominal organs or blood vessels.

Staging pancreatic cancer
Staging tests help determine the size and location of cancer and whether it has spread. They’re crucial in helping your doctor determine the best treatment for you. Pancreatic cancer may be staged in several ways. One method is to use these terms:

• Resectable. All the tumor nodules can be removed.
• Locally advanced. Because the cancer has spread to tissues around the pancreas or into the blood vessels, it can no longer be completely removed.
• Metastatic. At this stage, the cancer has spread to distant organs, such as the lungs and liver.

Your doctor may also refer to your cancer as stage 1, 2, 3, or 4:

• Stage 1 pancreatic cancer is confined to the pancreas.
• Stage 2 pancreatic cancer has spread somewhat, possibly to the lymph nodes, but not into large blood vessels nearby.
• Stage 3 pancreatic cancer has invaded large blood vessels, may be in the lymph nodes, but hasn’t spread to distant sites.
• Stage 4 means the cancer has spread to a distant site or sites in your body.

Complications

Your pancreas produces a number of enzymes that break down food so your body can absorb the nutrients it contains. But pancreatic tumors often interfere with the production or flow of these enzymes. As a result, your body can’t easily absorb nutrients, which can lead to diarrhea and severe weight loss.

Other complications of pancreatic cancer include:

• Problems with glucose metabolism. Tumors that affect the ability of your pancreas to produce insulin can lead to problems with glucose metabolism, including diabetes.
• Jaundice, sometimes with severe itching. Yellowing of your skin and the whites of your eyes can develop when a pancreatic tumor blocks your bile duct, the thin tube that carries bile from your liver to your duodenum. The yellow color comes from excess bilirubin. Bile acids may cause intense itching when they build up in your skin.
• Pain. Large pancreatic tumors may press on surrounding nerves, leading to back or abdominal pain that may sometimes be severe. Often, your doctor can prescribe medications that help relieve pain. When medications aren’t enough, cutting or injecting alcohol into some of the affected nerves may be an option.
• Metastasis. This is the most serious complication of pancreatic cancer. Your pancreas is surrounded by a number of vital organs, including your stomach, spleen, liver, lungs and intestine. Because pancreatic tumors are rarely discovered in the early stages, they often have time to spread to these organs or to nearby lymph nodes.

Treatment

Treatment for pancreatic cancer depends on the stage and location of the cancer as well as on your age, overall health and personal preferences. Especially when cancer is advanced, choosing a treatment plan is a major decision, and it’s important to carefully evaluate your choices.

You may also want to consider seeking a second opinion. This can provide additional information to help you feel more certain about the option you’re considering.

The first goal of treatment is always to eliminate the cancer completely. When that isn’t possible, the focus may be on preventing the tumor from growing or causing more harm. In some cases, an approach called palliative care may be best. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms and making you as comfortable as possible.

Surgical options
The only way to eliminate pancreatic cancer is an operation to remove the tumor. Unfortunately, this is possible only in a small percent of people. Once the cancer has spread beyond the pancreas to other organs, lymph nodes or blood vessels, surgery is usually no longer an option. When surgery is possible, your surgeon may use one of the following procedures, depending on the extent and location of the tumor:

• Whipple procedure (pancreatoduodenectomy). This is the most common procedure for treating pancreatic cancer, including resectable cancers of the ampulla of Vater. In general, the Whipple procedure involves removing the wide end (head) of your pancreas. To do that, your surgeon must also remove your duodenum, gallbladder and the end of the common bile duct. Sometimes part of your stomach is removed as well. The end of your bile duct and remaining part of your pancreas are then connected to your small intestine so that bile and pancreatic enzymes continue to reach the small intestine. The procedure has risks, including infection and bleeding.
• Total pancreatectomy. In this procedure, your surgeon removes your entire pancreas as well as your bile duct, gallbladder and spleen; part of your small intestine and stomach; and most of the lymph nodes in the area. After a total pancreatectomy, you’ll need insulin injections and pancreatic enzymes, and the operation presents serious risks. Total pancreatectomy isn’t often used for people with pancreatic cancer because there doesn’t appear to be enough benefit from the procedure to justify the risks.
• Distal pancreatectomy. In this procedure, which is primarily used to treat islet cell cancers, only the tail — or the tail and a small portion of the body of your pancreas — is removed. Sometimes your spleen may also be removed.

Operations for pancreatic cancer are complex. The most successful outcomes generally occur when these procedures are performed in cancer centers by highly experienced surgeons.

Radiation therapy
Radiation therapy uses high-energy X-rays to destroy cancer cells. You may receive radiation treatments before or after cancer surgery, often in combination with chemotherapy. Or, your doctor may recommend a combination of radiation and chemotherapy treatments when your cancer can’t be treated surgically.

Radiation that comes from a machine outside your body (external beam radiation) is generally used to treat pancreatic cancer. Side effects of radiation therapy may include a burn on your skin similar to sunburn where the radiation enters your body, nausea, vomiting and fatigue.

Doctors at some cancer centers are studying a new approach to radiation therapy, called intraoperative electron beam radiation. In this procedure, a type of external beam radiation that uses high-energy particles (electrons) is directed at your pancreas during surgery. This allows doctors to treat a pancreatic tumor with a high dose of radiation while sparing nearby organs.

Chemotherapy
Chemotherapy uses drugs to help kill cancer cells. Injected into a vein or taken orally, these drugs travel through your bloodstream. For that reason, they’re often used to treat cancers that have spread. Chemotherapy, or chemotherapy in combination with radiation, is the usual treatment for pancreatic cancers that have spread to nearby tissues or distant organs. Although chemotherapy won’t eliminate the cancer, it may help relieve symptoms. It may also help improve survival when used as an adjuvant therapy after an operation to remove a tumor in the pancreas.

For years, the drug fluorouracil (5-FU) was the only chemotherapy option for people with pancreatic cancer. But fluorouracil wasn’t always effective. Now doctors are having more success with a newer drug, gemcitabine. The drug is normally used alone but may be used in combination with other drugs as part of a clinical trial. In November 2005, the U.S Food and Drug Administration (FDA) approved the combination of gemcitabine and erlotinib to treat advanced pancreatic cancer that hasn’t responded to other treatments. While this combination isn’t a cure, it does increase the life expectancy for some people. Doctors are also testing a number of other new medications and new combinations of older medicines.

Chemotherapy drugs affect normal cells as well as malignant ones, especially fast-growing cells in your digestive tract and bone marrow. For that reason, side effects — including nausea and vomiting, mouth sores, an increased chance of infection due to a shortage of white blood cells, and fatigue — are common. Not everyone experiences side effects, however, and there are new and better ways to control them if you do. Be sure to discuss any questions you may have about side effects with your treatment team.

Clinical trials
If you have advanced pancreatic cancer, you may want to consider participating in a clinical trial. This is a study that is used to test new forms of therapy — typically new drugs, different approaches to surgery or radiation treatments, and novel methods such as gene therapy. If the therapy being tested proves to be safer or more effective than current treatments, it will become the new standard of care.

Remember that the treatments used in clinical trials haven’t yet been shown to be effective. They may have serious or unexpected side effects, and there’s no guarantee you’ll benefit from them.

On the other hand, cancer clinical trials are closely monitored by the federal government to ensure they’re conducted as safely as possible. And they offer access to treatments that wouldn’t otherwise be available to you.

If you’re interested in finding out more about clinical trials, talk to your treatment team. You can also call the National Cancer Institute’s Cancer Information Service at (800) 4-CANCER, or (800) 422-6237.

Palliative procedures
If your cancer has spread too far to be completely removed by an operation, the primary goal will be to relieve your signs and symptoms. Treatments that focus on making you more comfortable include:

• Surgical bypass. Tumors that block your bile duct, pancreatic duct or duodenum can cause pain, digestive difficulties, nausea, vomiting, jaundice and severe itching. To help ease some of these symptoms, you may have an operation to reroute the flow of bile by going around (bypassing) the tumor.
• Stent insertion. When a bypass operation isn’t an option, your surgeon may place a stainless steel or plastic tube (stent) in the bile duct to keep it open. A stent is usually the best choice for people who have metastatic cancer or who are very weak.
• Pain management. Tumors pressing on surrounding nerves can cause severe pain, especially in the later stages of the disease. Although pain is a real concern for people with pancreatic cancer, treatment with morphine or similar medications can provide relief in many cases. Long-lasting forms of morphine that need to be taken only once or twice a day may be especially helpful. When medication isn’t enough, your doctor may discuss other options with you, such as cutting some of the nerves that transmit pain signals or injecting alcohol into these nerves to block the sensation of pain.
• Pancreatic enzyme tablets. By replacing the digestive enzymes your pancreas no longer produces, these tablets can improve your body’s ability to absorb nutrients and may help reduce diarrhea and weight loss.
• Insulin therapy. When pancreatic cancer affects insulin production, you may need insulin injections to help control your blood sugar levels.

New treatments
Researchers are studying a number of other approaches to treating pancreatic cancer, including:

• Anti-angiogenesis factors. Cancer cells need angiogenesis factors to produce new blood vessels so they can grow and spread. Scientists have developed drugs that stop this process.
• Farnesyl transferase inhibitors. Most people with pancreatic cancer have cells that contain a specific genetic mutation. In order to function, the mutated cells need an enzyme called farnesyl transferase. Now researchers have developed drugs that block the action of farnesyl transferase, causing the mutated cells to die. Studies of these drugs are under way.
• Growth factor inhibitors. Growth factor receptors help some malignant cells grow. Drugs that block these receptors, such as cetuximab, may help fight pancreatic cancer.

Prevention

Although it’s not always possible to prevent pancreatic cancer, these lifestyle changes may help reduce your risk:

• Quit smoking. Cigarette smoke contains carcinogens that can damage the DNA that regulates cell growth. Talk to your doctor about the best ways to quit, or contact the American Cancer Society or American Lung Association for more information.
• Maintain a healthy weight. Being overweight increases your risk of pancreatic cancer. If you need to lose weight, keep in mind that a slow, steady loss is the healthiest way to reach your goals. Aim for no more than 1 to 2 pounds a week. Add 30 minutes or more of aerobic exercise — such as walking, jogging or biking — on most days, and you can increase the amount of weight you lose.
• Exercise regularly. Experts believe that getting even a moderate amount of exercise every week can cut your risk of pancreatic cancer. For overall health, aim for 30 minutes of exercise on most days. If you’re not used to exercising, start out slowly and work up to your goal.
• Eat a healthy diet. A diet high in fruits and vegetables and low in animal fat can reduce your risk of pancreatic cancer.

Self-care

Poor appetite, weight loss and muscle wasting are often problems for people with pancreatic cancer. These symptoms may be compounded by cancer treatments as well as by the emotional toll of living with the disease. For that reason, your doctor may recommend talking to a registered dietitian. He or she can help you find ways to get the nourishment you need.

These suggestions also may help:

• Reduce the size of your meals. Try eating several small meals throughout the day instead of two or three larger ones. If you’re nauseous, choose foods that are soothing and easy-to-digest, such as soups, rice or a plain baked potato.
• Restrict dietary fat. Follow your doctor’s recommendations for reducing fat in your diet. Pancreatic cancer affects your body’s ability to digest fats.
• Consider dietary supplements. With pancreatic cancer, your body can’t easily absorb nutrients. Talk to your doctor about vitamin and mineral supplements.
• Have nourishing snacks within easy reach. That way, you’re more likely to eat. Fresh fruit, nonfat yogurt or carrot sticks are all good choices.
• Don’t worry if you have days when you can’t eat at all. In the meantime, do whatever you can to make yourself feel better. Let your doctor know if you don’t feel better in a couple of days.
• Try to drink plenty of fluids. Water is essential for your body’s proper functioning.

Coping skills

Learning you have any life-threatening illness can be devastating. But coping with a diagnosis of pancreatic cancer can be especially difficult. The more advanced the disease when it’s discovered, the less likely the chance of real recovery. As a result, you may feel especially overwhelmed just when you need to make crucial decisions. Although there are no easy answers for people dealing with pancreatic cancer, some of the following suggestions may help:

• Learn all you can about your illness. Learn everything you can about pancreatic cancer — how the disease progresses, your prognosis and your treatment options, including both experimental and standard treatments and their side effects. Be sure you understand whether a particular approach is used to treat cancer or provide palliative care. Don’t be afraid to seek a second opinion and to explore treatments available through clinical trials. You will have many decisions to make in the weeks and months ahead. The more you know, the more active a role you can take in the decision-making process.In addition to talking to your medical team, look for information in books and reputable sources on the Internet. Some reliable sites are listed at the end of this article. In addition, the National Cancer Institute offers a toll-free information line called the Cancer Information Service that you can reach at (800) 4-CANCER, or (800) 422-6237.
• Maintain a strong support system. Strong relationships are crucial to dealing with life-threatening illnesses. Although friends and family can be your best allies, in some cases they may have trouble dealing with your illness. Or you may not have a large social network. If so, the concern and understanding of a counselor, medical social worker, pastoral or religious counselor, or even a formal support group can be helpful. Although support groups aren’t for everyone, they can sometimes be a good resource for practical information about your disease. You may also find strength and encouragement in being with people who are facing the same challenges you are.If you’re interested in learning more about support groups, talk to a doctor, nurse, social worker or psychologist. They may be able to put you in touch with a group in your area. Or check your local phone book, library or cancer organization. The National Cancer Institute also can provide a list of support groups. After deciding to participate in a group, try it out a few times. If it doesn’t seem useful or comfortable, you don’t have to continue.
• Come to terms with your illness. Coming to terms with your illness may be the hardest thing you’ve ever done. For some people, having a strong faith or a sense of something greater than themselves makes this process easier. Others seek counseling from someone who understands life-threatening illnesses, such as a medical social worker, psychologist or chaplain. Many people also take steps to ensure that their end-of-life wishes are known and respected.A great fear of many people with a life-threatening illness is being subjected to treatments they don’t want or spending their last weeks or months in a hospital away from loved ones and familiar surroundings. The welcome news is that many choices exist for people with a terminal illness.

  Hospice care, for example, provides a special course of treatment to terminally ill people. This allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one at home or in hospice residences. It also provides emotional, social and spiritual support for people who are ill and those closest to them. Although most people under hospice care remain in their own homes, the program is available anywhere — including nursing homes and assisted-living centers. For people who stay in a hospital, palliative care specialists can provide comfort, compassionate care and dignity.

  Although it can be extremely difficult, discuss end-of-life issues with your family and medical team. Part of this discussion will likely involve advance directives — a general term for oral and written instructions you give concerning your medical care should you become unable to speak for yourself.

  One type of advance directive is known as a durable power of attorney (POA) for health care. In this case, you sign a legal document authorizing a person you respect and trust to make legally binding medical decisions for you if you’re unable to do so. A POA is often recommended because the appointed person can make decisions in situations not covered in a regular advance directive. Whatever you decide, it’s important to put your wishes in writing. Laws regarding advance directives and POAs vary from state to state, but a written document is more likely to be respected.

  To learn more about advance directives, you can contact the National Hospice and Palliative Care Organization at (800) 658-8898.

Complementary and alternative medicine

More and more people are interested in nontraditional approaches to healing, especially when standard treatments produce intolerable side effects or aren’t able to provide a cure. To address this growing interest, the National Institutes of Health established the National Center for Complementary and Alternative Medicine (NCCAM).

The center’s mission is to explore nontraditional therapies in a scientifically rigorous way. NCCAM and the National Cancer Institute have teamed up specifically to look at the role complementary and alternative medicine may play in the treatment of cancer.

In general, alternative medicine refers to therapies, such as mistletoe or coenzyme Q-10, that may be used instead of conventional treatments. Complementary or integrative medicine, on the other hand, usually means therapies used in conjunction with traditional treatments.

Rather than simply addressing a problem with the body, complementary and alternative treatments often focus on the entire person — body, mind and spirit. As a result, they can be especially effective at reducing stress, alleviating the side effects of conventional treatments such as chemotherapy, and improving quality of life. However, these products aren’t regulated by the FDA, so you can’t be sure of a product’s quality. Additionally, some of these substances can interfere with your treatment. Check with your doctor before taking alternative medications.

NCCAM’s findings are available on its Web site. You can also talk to information specialists at NCCAM’s clearinghouse by calling (888) 644-6226.