Dr. Praveen Sharma

Flatulence, known as farting, is a medical term for releasing gas from the digestive system through the anus. It occurs when gas collects inside the digestive system; however, one should not worry because it is a normal process.

Flatulence is due to swallowed air, the breakdown of undigested foods, lactose intolerance, and malabsorption of certain foods. Some foods that increase gas include beans, cabbage, broccoli, raisins, lentil, prunes, apples, and foods that are high in fructose or sorbitol, such as fruit juices. These foods can take a long time to digest, leading to the unpleasant smell associated with flatulence.If this condition is in excess, it can be because of various pathological conditions, such as constipation, gastroenteritis, irritable bowel syndrome, Crohn’s disease, diabetes, ulcerative colitis, GERD, peptic ulcers, etc.

About 99% of the volume of flatus is composed of non-smelly gases. These include oxygen, nitrogen, carbon dioxide, hydrogen and methane. Volume range of normal flatus is around 476–1,491 mL per 24 hours. The normal range of flatus episodes is given as 8–20 per day.

Usually, this condition presents with increased frequency or excessive instances of passing gas, belching, foul-smelling gas production, abdominal bloating and/or abdominal pain or discomfort.

Medical help should be considered if you experience symptoms, such as severe cramps, fever, diarrhea, bloody stools, nausea, and vomiting and/or right-sided abdominal pain along with gas or flatulence.

Flatulence can be diagnosed in the following ways:

Diagnosis is made with the help of the patient's history and physical examination.

Most of the times tests are not required, but if required analysis of patients' breath and flatus (gas passed out of the rectum) tests are done. Other tests, such as colonoscopy, X-rays and/or CT scans are rarely performed; it depends on the case.

Flatulence can be managed in the following ways:

1. Most commonly antibiotic treatment, increased dietary fiber intake, and probiotics in the diet are advised. In other conditions, such as IBS and Crohn’s disease, additional medications are given. Also, over-the-counter (OTC) medications are given, which include compounds such as Beano (an OTC that contains sugar–digestive enzyme), antacids, and activated charcoal.
2. Excessive flatulence can be reduced or prevented by avoiding dairy products if an individual is the lactose intolerant, by modifying eating habits, and by avoiding carbohydrates which are difficult to digest (instead of those you can add potatoes, rice, and bananas in your diet as the substitutes).
3. Eat small meals frequently which help in digestion.
4. Chew food properly. Restrain activities which may increase the amount of air that you swallow.
5. Do exercise. It helps improve digestion and prevent flatulence.
6. Some foods which help reduce gas are ginger, raw honey (not for infants and children under the age of 1 year), yogurt, peppermint, water, cinnamon, flaxseed, pineapple, fennel, and juices made from kale, spinach, or cucumbers.

Fatty liver is a condition where excess fat is deposited on this organ. Also called as steatosis, this condition happens when more than 5- 10 percent of the weight of the liver is made up of fat.

Fatty liver is a common condition among people. A study from coastal regions of India found ~ 25% of healthy persons had patients had fatty liver on ultrasound.

It can occur at all ages including childhood, highest prevalence is in 40–50 year age group. Prevalence more in patient who are obese and in diabetic patients.

Types of Fatty Liver

1 Alcoholic fatty liver: This condition occurs when there is a heavy consumption of alcohol. Gastroenterologists recommend abstention from alcohol for this condition to subside. If the patient continues to consume alcohol, then liver cirrhosis may develop.

2 Non alcoholic fatty liver (NAFL): One may develop a fatty liver even if one is not an alcoholic. The liver in some cases is unable to process the fat in cells causing them to build-up on the organ.

When more than 10% of the liver is made of fat then this condition is called Non Alcoholic Fatty Liver (NAFL).

Non alcoholic steatohepatitis (NASH): When fatty liver is associated with inflammation in liver patient is said to be having Non alcoholic steatohepatitis. NASH is a more advanced stage of NAFLD, and has a higher risk of progressing to liver cirrhosis or hepatocellular carcinoma (HCC). These condition display symptoms like jaundice, vomiting, nausea, loss of appetite and abdominal pain. Blood test (LFT) shows raised enzymes level. Approx 5-8% of the Indian population has NASH. Consult a doctor if you are experiencing any of these symptoms.

3 Fatty liver during pregnancy: Occurring mainly in the third trimester, the symptoms of this condition are vomiting, nausea, pain the right part of the abdomen and jaundice.

Symptoms

During the early stages (fatty liver) of the disease, patients usually have no symptoms directly related to liver disease. However, people may experience a vague abdominal discomfort. If their liver is inflamed (NASH) then they may display symptoms of poor appetite, weight loss, pain in the abdomen and disorientation.

What causes fatty liver?

The most common cause of fatty liver is alcoholism. When the human liver is unable to metabolize fat fast enough or when there is an excess accumulation of fat on the liver cells then the liver becomes fatty. However, intake of high-fat foods may not result in a fatty liver.

Predisposing factor:

1 Diabetes mellitus

2 Obesity or being overweight

3 Hyperlipidemia or the condition where there are high levels of fat in the blood

4 Genetic reasons

5 Rapid loss of weight

6 Drugs: Aspirin, steroids, tamoxifen, tetracycline etc. cause side effects which also leads to fatty liver

7 Nutritional status (eg, overnutrition, severe malnutrition, total parenteral nutrition [TPN], or starvation diet)

8 Other health problems (eg, Hepatitis C infection, celiac sprue and Wilson disease)

Bariatric surgery (weight loss surgery) includes a variety of procedures performed on people who have obesity. Metabolic surgery is defined as “a set of gastrointestinal operations performed with the intent to treat diabetes (diabetes surgery) and metabolic dysfunctions (which includes obesity). Over the past 5 years, the term “metabolic surgery” has become increasingly popular. In 2002, it was suggested that gastrointestinal surgery could be used with the primary intent to treat type 2 diabetes. The idea derived from the factor that the gastrointestinal tract is a major player in the regulation of glucose homeostasis.

In patients with a BMI above 35, surgical treatment of diabetes is now recommended by virtually all professional organizations.

Weight loss is achieved by:

1. Reducing the size of the stomach with a gastric band or through the removal of a portion of the stomach
2. By resecting and rerouting the small intestine to a small stomach pouch.

Statistics

Long-term studies show that the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a mortality reduction from 40% to 23%.

Indications for Bariatric Surgery

1. Excess body weight affecting the quality of life and restricting routine activities
2. Patients with a BMI of 40 kg/m2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy
3. Patients who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea

Types of Bariatric Surgery

1. Vertical sleeve surgery
2. Gastric bypass surgery 
3. Intragastric balloon surgery
4. Duodenal switch surgery
5. Lap band surgery

Eating Schedule After Bariatric Surgery

Immediately after bariatric surgery, the patient is restricted to a clear liquid diet until the gastrointestinal tract recovers from the surgery. This is followed by a blended diet for at least 2 weeks, consisting of a high protein diet and dairy products. Foods high in carbohydrates are usually avoided when possible during the initial weight-loss period. Many patients need to take a daily multivitamin pill to compensate for reduced absorption of essential nutrients. 

Effectiveness of Surgery

• Weight loss
• Reduced mortality and morbidity
• Psychiatric/psychological health can improve after bariatric surgery

Adverse Effects of Surgery

1. Metabolic bone disease manifesting as osteopenia and secondary hyperparathyroidism
2. Rapid weight loss after obesity surgery contributing to the development of gallstones
3. Hyperoxaluria that can potentially lead to oxalate nephropathy and irreversible renal failure
4. Rhabdomyolysis leading to acute kidney injury and impaired renal handling of acid and base balance has been reported after bypass surgery
5. Nutritional derangements due to deficiencies of micronutrients

Complications of Bariatric Surgery

• Anemia
• Osteoporosis and bone degeneration
• Malnutrition
• Dumping syndrome
• Erosion
• Spleen injury
• Suture-line disruption
• Long-term nausea and inability to tolerate food
• Hernia
• Migration of the band
• Narrowing of the stomach outlet (stenosis)
• Leakage
• Ulcers
• Constipation
• Nutritional deficiencies
• Weight Regain

Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach. Most people can manage the discomfort of GERD with lifestyle changes and over-the-counter medications. But som

Hepatitis refers to an inflammatory condition of the liver. Excessive alcohol consumption can cause liver damage and inflammation. Other toxic causes of hepatitis include overuse or overdose of medications and exposure to poisons.

The bile duct connects the liver, gall bladder and small intestine and plays an important role in the digestion process. Though it is rare, the bile duct may also be affected by cancer, this type of cancer is known as biliary cancer. Biliary cancer can be categorized as intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, and cancer of the gall bladder. Of these, gall bladder cancer is the most common. Biliary cancer is typically treated with surgery and followed by chemotherapy and radiation. In many cases, this surgery may be performed laparoscopically.

Laparoscopic surgery is also known as keyhole surgery or minimally invasive surgery. This differs from other surgical procedures as it allows a surgeon to operate on an internal organ without making a large incision. There are many advantages to laparoscopic surgery which include minimal bleeding, smaller internal and external scars, reduced chances of infections, lowered pain and discomfort and faster healing. It also reduces the amount of hospitalization required after a surgery and allows the patient to return to his normal lifestyle faster. However, laparoscopic surgery cannot be applied to all procedures.

When it comes to biliary cancer, laparoscopy can be used to treat cancer of the gall bladder. This is known as Laparoscopic cholecystectomy and involves the removal of part of the gallbladder or the whole gall bladder. The lymph nodes around the gall bladder and parts of the liver tissue may also be removed. For this procedure, 3 to 4 incisions may be made in the abdomen. A long flexible tube with a light and camera at one end is passed through one of these incisions. This allows the surgeons to look inside the abdominal cavity. Instruments are used through the other incisions to cut the tumor away and remove it.

Laparoscopy is rarely used to treattumours in the bile ducts. This is because the bile ducts are relatively small and placed deep within the abdomen. However, if a tumor is blocking the flow of bile into the intestines, laparoscopy may be used to create a bypass. It may also be used to remove small stones from the bile duct.

Biliary cancer has very few significant symptoms. Hence, in many cases, it is diagnosed only at an advanced stage. Almost all cases of Biliary cancer are accompanied by the development of gall stones. Laparoscopy is very effective in treating gall stones and increases the chances of detecting biliary cancer in its early stage

• Irregular food habits
• Stress
• Lack of proper sleep
• Smoking and alcohol
• Lack of exercises