Chest X-Ray

What is a chest X-ray?

A chest X-ray is a radiology test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest. An X-ray film is positioned against the body opposite the camera, which sends out a very small dose of a radiation beam. As the radiation penetrates the body, it is absorbed in varying amounts by different body tissues depending on the tissue's composition of air, water, blood, bone, or muscle. Bones, for example, absorb much of the X-ray radiation while lung tissue (which is filled with mostly air) absorbs very little, allowing most of the X-ray beam to pass through the lung.

What is a shadow on a chest X-ray?

Due to the differences in their composition (and, therefore, varying degrees of penetration of the X-ray beam), the lungs, heart, aorta, and bones of the chest each can be distinctly visualized on the chest X-ray. The X-ray film records these differences to produce an image of body tissue structures and these are shadows seen on the X-ray. The white shadows on chest X-ray represent more dense or solid tissues, such as bone or heart, and the darker shadows on the chest X-ray represent air filled tissues, such as lungs.

How is the chest X-ray procedure performed?

Patients obtaining a chest X-ray will often be requested to use an X-ray gown, and extra metallic objects such as jewelry are removed from the chest and/or neck areas. These objects can block X-ray penetration, making the result less accurate. Patients may be asked to take a deep breath and hold it during the chest X-ray in order to inflate the lungs to their maximum, which increases the visibility of different tissues within the chest.
The chest X-ray procedure often involves a view from the back to the front of the body as well as a view from the side. The view from the side is called a lateral chest X-ray. Occasionally, different angles are added in order for the radiologist to interpret certain specific areas of the chest.
The radiology technologist or technician is a trained, certified assistant to the radiologist who will help the patient during the X-ray and actually perform the X-ray test procedure. After the chest X-ray is taken and recorded on the X-ray film, the film is placed into a developing machine, and this picture (which is essentially a photographic negative) is examined and interpreted by the radiologist.

How do doctors interpret chest X-rays?

A radiologist is a physician specialist trained to interpret images of the body produced on films. After the films are produced by the technician they are developed and reviewed by the radiologist for interpretation. After the radiologist reviews the chest X-ray, occasionally further images or angles may be necessary. Once all the films have been reviewed by the radiologist, a report is generated which is transmitted to the ordering practitioner.
The doctors interpreting the films place the films in front of a source of light for better visualization of the shadows on the chest X-ray. This usually consists of a fluorescent light source placed in metal box and covered by a white plastic.
More recently, newer technology has replaced this old reading technique in many health care facilities and radiology offices. This advanced technology has eliminated the need for the actual physical films to be placed on a light box for interpretation. The images, once taken and developed, are uploaded into a computer with special software that enables digital images to be viewed on a computer screen. The doctor can look at the images on the screen, interpret the results, and comment on the computer all within minutes after the images were taken.
Additionally, this technology may allow for ability to look at any previous images taken from the same patient. It also essentially eliminates the possibility of lost X-rays and speeds up the interpretation of X-rays, and the communication between doctors about the results.

Where are chest X-ray's performed?

Chest X-rays are one the most commonly ordered radiology tests. Once they are ordered by a physician, they can be performed in hospitals, emergency rooms, outpatient radiology facilities, and some doctors offices.

What are the risks of a chest X-ray?

Chest X-rays expose the patient briefly to a minimum amount of radiation. Any radiation exposure has some risk to the tissues of the body. The radiation exposure in a chest X-ray is minimized by the type of X-ray high-speed film, which does not require as much radiation exposure as in the past. The radiology technician is guided by technique standards which have been established by national and international guidelines. These guidelines are designed and reviewed by both the Department of Health and Human Services and national and international radiology protection councils.
Women, who are pregnant, especially in early pregnancy, should notify their physicians, as the fetus is at risk for harm with any radiology technique. X-rays are typically avoided in pregnant patients unless absolutely necessary, in which case, the patient's abdomen is covered with a special gown to deflect the radiation from the fetus.

What are reasons for ordering chest X-rays?

There are many reasons why doctors order chest X-rays. Frequently, they are ordered for symptoms of shortness of breath, cough, or chest pain. However, there are many other signs and symptoms that may prompt a doctor to order chest X-rays. They may also be done as a routine check examination.
Sometimes chest X-rays are required before operations to see if there is any evidence of heart or lung disease that may need to be addressed before the procedure. This is called a pre-operative chest X-ray (or pre-op chest X-ray requirement).

Who can interpret chest X-rays?

Many doctors are trained to interpret chest X-rays. In addition to radiologists, who have special training in reading all radiology films, primary care physicians, internists, pediatricians, emergency room doctors, anesthesiologists, heart doctors (cardiologist), lung doctors (pulmonologist) and lung surgeons are the doctors who frequently interpret chest X-rays as a part of their routine practice.

What can be seen on normal chest X-ray?

Normal chest X-ray shows normal size and shape of the chest wall and the main structures in the chest.
As described earlier, white shadows on the chest X-ray signify solid structures and fluids such as, bone of the rib cage, vertebrae, heart, aorta, and bones of the shoulders. The dark background on the chest X-rays represents air filled lungs. These lung fields are seen on either side of the heart and the vertebrae located in the center of the film.

What are some common chest X-ray abnormalities?

Chest X-ray is generally used in combination with other clinical data such as, physical examination and the patient's history and symptoms. It can also be used in combination of other radiology test to support, confirm, or exclude many conditions or diagnoses.
A chest X-ray can be used to define abnormalities of the lungs such as excessive fluid (fluid overload or pulmonary edema) fluid around the lung (pleurisy), pneumonia, bronchitis, asthma, cysts, and cancers. Heart abnormalities, including fluid around the heart (pericarditis), an enlarged heart (cardiomegaly), heart failure, or abnormal anatomy of the heart can be revealed on the films. Certain bony structures of the chest and broken bones (rib fracture) or abnormalities of the bones of the spine (vertebral fracture) in the chest can often be detected.

Chest X-Ray At A Glance

• A chest X-ray is most commonly used to detect abnormalities in the lungs, but can also detect abnormalities in the heart, aorta, and the bones of the thoracic area.
  
• Extra metallic objects, such as jewelry are removed from the chest and neck areas for a chest X-ray to avoid interference with X-ray penetration and improve accuracy of the interpretation.
  
  
• A chest X-ray can be used to diagnose many conditions and diseases such as pleurisy, pulmonary edema, pneumonia, bronchitis, cysts, tumors, cancers, asthma, pericarditis, cardiomegaly, heart failure, and fractures.

What is multiple myeloma?

Multiple myeloma is a type of cancer. Cancer is a group of many related diseases. Myeloma is a cancer that starts in plasma cells, a type of white blood cell. It's the most common type of plasma cell cancer.

Normal blood cells

Most blood cells develop from cells in the bone marrow called stem cells. Bone marrow is the soft material in the center of most bones.

Stem cells mature into different types of blood cells. Each type has a special job:

• White blood cells help fight infection. There are several types of white blood cells.
• Red blood cells carry oxygen to tissues throughout the body.
• Platelets help form blood clots that control bleeding.

Plasma cells are white blood cells that make antibodies. Antibodies are part of the immune system. They work with other parts of the immune system to help protect the body from germs and other harmful substances. Each type of plasma cell makes a different antibody.

Myeloma cells

Myeloma, like other cancers, begins in cells. In cancer, new cells form when the body doesn't need them, and old or damaged cells don't die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Myeloma begins when a plasma cell becomes abnormal. The abnormal cell divides to make copies of itself. The new cells divide again and again, making more and more abnormal cells. These abnormal plasma cells are called myeloma cells.

In time, myeloma cells collect in the bone marrow. They may damage the solid part of the bone. When myeloma cells collect in several of your bones, the disease is called "multiple myeloma." This disease may also harm other tissues and organs, such as the kidneys.

Myeloma cells make antibodies called M proteins and other proteins. These proteins can collect in the blood, urine, and organs.

Normal plasma cells help protect the body from germs and other harmful substances.

Myeloma cell (abnormal plasma cell) making M proteins.

Risk factors No one knows the exact causes of multiple myeloma. Doctors seldom know why one person develops this disease and another doesn't. However, we do know that multiple myeloma isn't contagious. You cannot catch it from another person. Research has shown that certain risk factors increase the chance that a person will develop this disease. Studies have found the following risk factors for multiple myeloma: Age over 65: Growing older increases the chance of developing multiple myeloma. Most people with myeloma are diagnosed after age 65. This disease is rare in people younger than 35. Race: The risk of multiple myeloma is highest among African Americans and lowest among Asian Americans. The reason for the difference between racial groups is not known. Being a man: Each year in the United States, about 11,200 men and 8,700 women are diagnosed with multiple myeloma. It is not known why more men are diagnosed with the disease. Personal history of monoclonal gammopathy of undetermined significance (MGUS): MGUS is a benign condition in which abnormal plasma cells make M proteins. Usually, there are no symptoms, and the abnormal level of M protein is found with a blood test. Sometimes, people with MGUS develop certain cancers, such as multiple myeloma. There is no treatment, but people with MGUS get regular lab tests (every 1 or 2 years) to check for a further increase in the level of M protein. They also get regular exams to check for the development of symptoms. Family history of multiple myeloma: Studies have found that a person's risk of multiple myeloma may be higher if a close relative had the disease. Many other suspected risk factors are under study. Researchers have studied whether being exposed to certain chemicals or germs (especially viruses), having alterations in certain genes, eating certain foods, or being obese increases the risk of developing multiple myeloma. Researchers continue to study these and other possible risk factors. Having one or more risk factors does not mean that a person will develop myeloma. Most people who have risk factors never develop cancer. Symptoms Common symptoms of multiple myeloma include: Bone pain, usually in the back and ribs Broken bones, usually in the spine Feeling weak and very tired Feeling very thirsty Frequent infections and fevers Weight loss Nausea or constipation Frequent urination Most often, these symptoms are not due to cancer. Other health problems may also cause these symptoms. Only a doctor can tell for sure. Anyone with these symptoms should tell the doctor so that problems can be diagnosed and treated as early as possible. Diagnosis Doctors sometimes find multiple myeloma after a routine blood test. More often, doctors suspect multiple myeloma after an x-ray for a broken bone. Usually though, patients go to the doctor because they are having other symptoms. To find out whether such problems are from multiple myeloma or some other condition, your doctor may ask about your personal and family medical history and do a physical exam. Your doctor also may order some of the following tests: Blood tests: The lab does several blood tests: Multiple myeloma causes high levels of proteins in the blood. The lab checks the levels of many different proteins, including M protein and other immunoglobulins (antibodies), albumin, and beta-2-microglobulin. Myeloma may also cause anemia and low levels of white blood cells and platelets. The lab does a complete blood count to check the number of white blood cells, red blood cells, and platelets. The lab also checks for high levels of calcium. To see how well the kidneys are working, the lab tests for creatinine. Urine tests: The lab checks for Bence Jones protein, a type of M protein, in urine. The lab measures the amount of Bence Jones protein in urine collected over a 24-hour period. If the lab finds a high level of Bence Jones protein in your urine sample, doctors will monitor your kidneys. Bence Jones protein can clog the kidneys and damage them. X-rays: You may have x-rays to check for broken or thinning bones. An x-ray of your whole body can be done to see how many bones could be damaged by the myeloma. Biopsy: Your doctor removes tissue to look for cancer cells. A biopsy is the only sure way to know whether myeloma cells are in your bone marrow. Before the sample is taken, local anesthesia is used to numb the area. This helps reduce the pain. Your doctor removes some bone marrow from your hip bone or another large bone. A pathologist uses a microscope to check the tissue for myeloma cells. There are two ways your doctor can obtain bone marrow. Some people will have both procedures during the same visit: Bone marrow aspiration: The doctor uses a thick, hollow needle to remove samples of bone marrow. Bone marrow biopsy: The doctor uses a very thick, hollow needle to remove a small piece of bone and bone marrow. You may want to ask your doctor these questions before having a bone marrow aspiration or biopsy: Will you remove the sample of bone marrow from the hip or from another bone? Where will I go for this procedure? Will I have to do anything to prepare for it? How long will it take? Will I be awake? Will it hurt? What will you do to prevent or control the pain? Are there any risks? What are the chances of infection or bleeding after the procedure? How long will it take me to recover? How soon will I know the results? Who will explain them to me? If I do have multiple myeloma, who will talk to me about next steps? When? Staging If the biopsy shows that you have multiple myeloma, your doctor needs to learn the extent (stage) of the disease to plan the best treatment. Staging may involve having more tests: Blood tests: For staging, the doctor considers the results of blood tests, including albumin and beta-2-microglobulin. CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your bones. MRI: A powerful magnet linked to a computer is used to make detailed pictures of your bones. Doctors may describe multiple myeloma as smoldering, Stage I, Stage II, or Stage III. The stage takes into account whether the cancer is causing problems with your bones or kidneys. Smoldering multiple myeloma is early disease without any symptoms. For example, there is no bone damage. Early disease with symptoms (such as bone damage) is Stage I. Stage II or III is more advanced, and more myeloma cells are found in the body. Treatment People with multiple myeloma have many treatment options. The options are watchful waiting, induction therapy, and stem cell transplant. Sometimes a combination of methods is used. Radiation therapy is used sometimes to treat painful bone disease. It may be used alone or along with other therapies. See the Supportive Care section to learn about ways to relieve pain. The choice of treatment depends mainly on how advanced the disease is and whether you have symptoms. If you have multiple myeloma without symptoms (smoldering myeloma), you may not need cancer treatment right away. The doctor monitors your health closely (watchful waiting) so that treatment can start when you begin to have symptoms. If you have symptoms, you will likely get induction therapy. Sometimes a stem cell transplant is part of the treatment plan. When treatment for myeloma is needed, it can often control the disease and its symptoms. People may receive therapy to help keep the cancer in remission, but myeloma can seldom be cured. Because standard treatment may not control myeloma, you may want to talk to your doctor about taking part in a clinical trial. Clinical trials are research studies of new treatment methods. See the Taking Part in Cancer Research section. Your doctor can describe your treatment choices, the expected results, and the possible side effects. You and your doctor can work together to develop a treatment plan that meets your needs. Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat multiple myeloma include hematologists and medical oncologists. Your health care team may also include an oncology nurse and a registered dietitian. Before treatment starts, ask your health care team to explain possible side effects and how treatment may change your normal activities. Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next. You may want to ask your doctor these questions before you begin treatment: What stage of myeloma do I have? Is the disease affecting my kidneys? How do I get a copy of the report from the pathologist? What are my treatment choices? Which do you recommend for me? Why? Will I have more than one kind of treatment? How will my treatment change over time? What are the expected benefits of each kind of treatment? What are the risks and possible side effects of each treatment? What can we do to control the side effects? What can I do to prepare for treatment? Will I need to stay in the hospital? If so, for how long? What is the treatment likely to cost? Will my insurance cover the cost? How will treatment affect my normal activities? Would a clinical trial be right for me? Can you help me find one? How often should I have checkups? Watchful waiting People with smoldering myeloma or Stage I myeloma may be able to put off having cancer treatment. By delaying treatment, you can avoid the side effects of treatment until you have symptoms. If you and your doctor agree that watchful waiting is a good idea, you will have regular checkups (such as every 3 months). You will receive treatment if symptoms occur. Although watchful waiting avoids or delays the side effects of cancer treatment, this choice has risks. In some cases, it may reduce the chance to control myeloma before it gets worse. You may decide against watchful waiting if you don't want to live with untreated myeloma. If you choose watchful waiting but grow concerned later, you should discuss your feelings with your doctor. Another approach is an option in most cases. You may want to ask your doctor these questions before choosing watchful waiting: If I choose watchful waiting, can I change my mind later on? Will the cancer be harder to treat later? How often will I have checkups? Between checkups, what problems should I tell you about?  Induction therapy Many different types of drugs are used to treat myeloma. People often receive a combination of drugs, and many different combinations are used to treat myeloma. Each type of drug kills cancer cells in a different way: Chemotherapy: Chemotherapy kills fast-growing myeloma cells, but the drug can also harm normal cells that divide rapidly. Targeted therapy: Targeted therapies use drugs that block the growth of myeloma cells. The targeted therapy blocks the action of an abnormal protein that stimulates the growth of myeloma cells. Steroids: Some steroids have antitumor effects. It is thought that steroids can trigger the death of myeloma cells. A steroid may be used alone or with other drugs to treat myeloma. You may receive the drugs by mouth or through a vein (IV). The treatment usually takes place in an outpatient part of the hospital, at your doctor's office, or at home. Some people may need to stay in the hospital for treatment. The side effects depend mainly on which drugs are given and how much: Blood cells: When a drug used for myeloma treatment lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop therapy for a while or reduce the dose of drug. There are also medicines that can help your body make new blood cells. Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may be somewhat different in color and texture. Cells that line the digestive tract: Chemotherapy and targeted therapy can cause poor appetite, nausea and vomiting, diarrhea, constipation, or mouth and lip sores. Ask your health care team about medicines and other ways to help you cope with these problems. The drugs used for myeloma may also cause dizziness, drowsiness, numbness or tingling in hands or feet, and low blood pressure. Most of these problems go away when treatment ends. You may want to ask your doctor these questions before having induction therapy: Which drugs will I get? What will the treatment do? When will treatment start? When will it end? How often will I have treatments? Where will I go for treatment? Will I have to stay in the hospital? Will I have side effects during treatment? What side effects should I tell you about? Can I prevent or treat any of these side effects? Will there be lasting side effects? How long will they last? What can I do about them? How often will I need checkups? Stem cell transplant Many people with multiple myeloma may get a stem cell transplant. A stem cell transplant allows you to be treated with high doses of drugs. The high doses destroy both myeloma cells and normal blood cells in the bone marrow. After you receive high-dose treatment, you receive healthy stem cells through a vein. (It's like getting a blood transfusion.) New blood cells develop from the transplanted stem cells. The new blood cells replace the ones that were destroyed by treatment. Stem cell transplants take place in the hospital. Some people with myeloma have two or more transplants. Stem cells may come from you or from someone who donates their stem cells to you: From you: An autologous stem cell transplant uses your own stem cells. Before you get the high-dose chemotherapy, your stem cells are removed. The cells may be treated to kill any myeloma cells present. Your stem cells are frozen and stored. After you receive high-dose chemotherapy, the stored stem cells are thawed and returned to you. From a family member or other donor: An allogeneic stem cell transplant uses healthy stem cells from a donor. Your brother, sister, or parent may be the donor. Sometimes the stem cells come from a donor who isn't related. Doctors use blood tests to be sure the donor's cells match your cells. Allogeneic stem cell transplants are under study for the treatment of multiple myeloma. From your identical twin: If you have an identical twin, a syngeneic stem cell transplant uses stem cells from your healthy twin. There are two ways to get stem cells for people with myeloma. They usually come from the blood (peripheral blood stem cell transplant). Or they can come from the bone marrow (bone marrow transplant). After a stem cell transplant, you may stay in the hospital for several weeks or months. You'll be at risk for infections because of the large doses of chemotherapy you received. In time, the transplanted stem cells will begin to produce healthy blood cells. You may want to ask your doctor these questions before having a stem cell transplant: What kind of stem cell transplant will I have? If I need a donor, how will we find one? How long will I be in the hospital? Will I need special care? How will I be protected from germs? Will my visitors have to wear a mask? Will I? What care will I need when I leave the hospital? How will we know if the treatment is working? What are the risks and the side effects? What can we do about them? What changes in normal activities will be necessary? What is my chance of a full recovery? How long will that take? How often will I need checkups? Second opinion Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. If you get a second opinion, the doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach. Either way, you have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at your options. It may take some time and effort to gather your medical records and see another doctor. In most cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually won't make treatment less effective. To make sure, you should discuss this delay with your doctor. Some people with multiple myeloma need treatment right away. There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists. NCI's Cancer Information Service at 1-800-4-CANCER can tell you about nearby treatment centers. Supportive care Multiple myeloma and its treatment can lead to other health problems. At any stage of the disease, you can have supportive care. Supportive care is treatment to prevent or fight infections, to control pain and other symptoms, to relieve the side effects of therapy, and to help you cope with the feelings that a diagnosis of cancer can bring. You may receive supportive care to prevent or control these problems and to improve your comfort and quality of life during treatment. You can get information about supportive care on NCI's Web site at http://www.cancer.gov/cancerinfo/coping and from NCI's Cancer Information Service at 1-800-4-CANCER or LiveHelp (http://www.cancer.gov/help). Infections Because people with multiple myeloma get infections very easily, you may receive antibiotics and other drugs. Some people receive vaccines against the flu and pneumonia. You may want to talk with your health care team about when to get certain vaccines. The health care team may advise you to stay away from crowds and from people with colds and other contagious diseases. If an infection develops, it can be serious and should be treated promptly. You may need to stay in the hospital for treatment. Anemia Myeloma and its treatment can lead to anemia, which may make you feel very tired. Drugs or a blood transfusion can help with this problem. Pain Multiple myeloma often causes bone pain. Your health care provider can suggest ways to relieve or reduce pain: A brace that relieves pain in the neck or back Drugs that fight pain anywhere in the body Radiation therapy from a large machine aimed at the bone Surgery to fix a compressed (squeezed) spinal cord Some people get pain relief from massage or acupuncture when used along with other approaches. Also, you may learn relaxation techniques such as listening to slow music or breathing slowly and comfortably. Thinning bones Myeloma cells keep new bone cells from forming, and bones become thin wherever there are myeloma cells. Your doctor may give you drugs to prevent bone thinning and help reduce the risk of fractures. Physical activity, such as walking, also helps keep bones strong. Too much calcium in the blood Multiple myeloma may cause calcium to leave the bones and enter the bloodstream. If you have a very high level of calcium in your blood, you may lose your appetite. You also may feel nauseated, restless, or confused. A high calcium level can also make you very tired, weak, dehydrated, and thirsty. Drinking a lot of fluids and taking drugs that lower the calcium in the blood can be helpful. Kidney problems Some people with multiple myeloma have kidney problems. If the problems are severe, a person may need dialysis. Dialysis removes wastes from the blood. A person with serious kidney problems may need a kidney transplant. Amyloidosis Some people with myeloma develop amyloidosis. This problem is caused by abnormal proteins collecting in tissues of the body. The buildup of proteins can cause many problems, some of them severe. For example, proteins can build up in the heart, causing chest pain and swollen feet. There are drugs to treat amyloidosis. Nutrition and physical activity It's important for you to take care of yourself by eating well, drinking plenty of fluids, and staying as active as you can. You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy. However, you may not feel like eating during treatment or soon after. You may be uncomfortable or tired. You may find that foods do not taste as good as they used to. In addition, the side effects of treatment (such as poor appetite, nausea, vomiting, or mouth sores) can make it hard to eat well. Your doctor, a registered dietitian, or another health care provider can suggest ways to deal with these problems. Research shows that people with cancer feel better when they are active. Walking, yoga, swimming, and other activities can keep you strong and increase your energy. Exercise may reduce nausea and pain and make treatment easier to handle. It also can help relieve stress. Whatever physical activity you choose, be sure to talk to your doctor before you start. Also, if your activity causes you pain or other problems, be sure to let your doctor or nurse know about it. Follow-up care You'll need regular checkups after treatment for multiple myeloma. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, you should contact your doctor. Your doctor will check for return of cancer. Even when the cancer seems to have been completely destroyed, the disease sometimes returns because undetected myeloma cells remained somewhere in the body after treatment. Also, checkups help detect health problems that can result from cancer treatment. Checkups may include a careful physical exam, blood tests, x-rays, or bone marrow biopsy. You may want to ask your doctor these questions after you have finished treatment: How often will I need checkups? Which follow-up tests do you suggest for me? Between checkups, what health problems or symptoms should I tell you about? Sources of support Learning you have myeloma can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to have new and confusing feelings to work through. Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities. Here's where you can go for support: Doctors, nurses, and other members of your health care team can answer many of your questions about treatment, working, or other activities. Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support. Support groups can also help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with the disease and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group. Information specialists at 1-800-4-CANCER and at LiveHelp (http://www.cancer.gov/help) can help you locate programs, services, and publications. They can give you names of national organizations that offer services to people with cancer and their families. Taking part in cancer research Doctors all over the country are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to answer important questions and to find out whether new approaches are safe and effective. Research already has led to advances in treatment, such as stem cell transplants. And doctors continue to look for better ways to treat myeloma. Researchers are testing new drugs and drug combinations. They are also testing ways to improve stem cell transplants for people with multiple myeloma. Even if people in a trial do not benefit directly, they still make an important contribution by helping doctors learn more about myeloma and how to control it. Although clinical trials may pose some risks, doctors do all they can to protect their patients. NCI's Web site includes a section on clinical trials at http://www.cancer.gov/clinicaltrials. It has general information about clinical trials as well as detailed information about specific ongoing studies of myeloma. Information specialists at 1-800-4-CANCER or at LiveHelp at http://www.cancer.gov/help can answer questions and provide information about clinical trials. Article Related Diseases smaller medium larger Previous 1 2 3 4 5 6 7 8 9 Next Multiple Myeloma (cont.) Breast Cancer Slideshow Pictures Pancreatic Cancer Slideshow Pictures Skin Cancer Slideshow Pictures In this Article What is multiple myeloma? What are multiple myeloma causes and risk factors? What are multiple myeloma symptoms and signs? How is multiple myeloma diagnosed? What are multiple myeloma stages? What is the treatment for multiple myeloma? What are methods of treatment for multiple myeloma? What supportive care can patients with multiple myeloma require? What happens after treatment for multiple myeloma? What support is available for cancer patients? What other resources are available to multiple myeloma patients? Multiple Myeloma At A Glance Patient Comments: Multiple Myeloma - Prognosis Patient Comments: Multiple Myeloma - Symptoms At Onset Of Disease Multiple Myeloma Glossary Multiple Myeloma Index Find a local Oncologist in your town National Cancer Institute information resources You may want more information for yourself, your family, and your doctor. The following NCI services are available to help you. Telephone NCI's Cancer Information Service (CIS) provides accurate, up-to-date information about cancer to patients and their families, health professionals, and the general public. Information specialists translate the latest scientific information into plain language, and they will respond in English or Spanish, as well as through TRS providers for the hearing or speech impaired. Calls to the CIS are confidential and free. Telephone: 1-800-4-CANCER (1-800-422-6237) Internet NCI's Web site provides information from numerous NCI sources. It offers current information about cancer prevention, screening, diagnosis, treatment, genetics, supportive care, and ongoing clinical trials. It has information about NCI's research programs, funding opportunities, and cancer statistics. Web site: http://www.cancer.gov Spanish Web site: http://www.cancer.gov/espanol If you're unable to find what you need on the Web site, contact NCI staff. Use the online contact form at http://www.cancer.gov/contact or send an email to cancergovstaff@mail.nih.gov. Also, information specialists provide live, online assistance through LiveHelp at http://www.cancer.gov/help. Multiple Myeloma At A Glance Multiple myeloma is a cancer of plasma cells in the bone marrow. Certain risk factors increase the chances of a person developing multiple myeloma. Symptoms of multiple myeloma vary depending on how advanced the disease is. Diagnosis of multiple myeloma is supported by findings of the medical history and examination, blood, urine and x-ray tests, and confirmed with a bone marrow aspiration and/or biopsy. Treatment of multiple myeloma depends on the patient's symptoms, extent of the disease, as well as the age and health of the patient. SOURCE: National Institues of Health, National Cancer Institute, www.cancer.gov

Acid-base balance

Normal values:
pH = 7.35-7.45
pO 2 = 12-15 kPa
pCO 2 = 4.4 – 5.6 kPa
Bicarb = 21-28 mmol/L

 

Four Steps:

1. 1. Assess oxygenation – pO 2 .
2. 2. Assess pH
3. 3. Determine primary problem by comparing direction of change of pCO 2 and pH.
   Opposite directions (i.e. a falling pH with a rising pCO 2 ) indicates primary respiratory problem.
   Same direction indicates primary metabolic problem.
4. 4. Assess compensation by comparing direction of change of pCO 2 and bicarbonate and applying a compensation rule. If no rule fits, then two problems are probably occurring simultaneously – see later.

Four compensation rules

1. 1. Acute respiratory acidosis: bicarbonate increases roughly 1mmol/L for every 1kPa elevation of pCO 2 above 5kPa.
2. 2. Chronic respiratory acidosis: bicarbonate increases roughly 3mmol/L for every 1kPa elevation of pCO 2 above 5kPa.
3. 3. Acute respiratory alkalosis: bicarbonate will decrease by 1.5 mmol/L for every 1kPa decrease in pCO 2 below 5kPa.
4. 4. Metabolic acidosis – predicted pCO2 = (bicarbonate/5) + 1

Understanding Compensation

Campbell 's simplification, simplified (the Sinclair equation):

The aim of compensation is to return the levels of H + to normal – either by varying carbon dioxide or bicarbonate levels: the component varied will be the opposite to the one causing the problem in the first place.
i.e.
In a respiratory problem (CO 2 levels causing imbalance) – compensate with bicarbonate .
In a metabolic problem (bicarbonate levels causing imbalance) – compensate with CO 2 .
e.g.
In metabolic acidosis – increased PaCO 2 causes a rise in H+. Therefore the body compensates by raising bicarbonate levels, thus lowering H+.
The amount by which the body has compensated will depend on the amount of time the compensation process has occurred over – so in acute acid-base imbalance, there will only be a small degree of compensation, but in chronic imbalances, full compensation will have taken place.
As a rule of thumb – if PaCO 2 and bicarbonate move in the same direction, compensation is occurring. Although note that if they move in opposite directions, more than one pathology may be present.

If you Didn't Get that...

Consider the following chemical equation:
CO2 + H2O <-> H2CO3 <-> H+ + HCO3-
Acidity is defined as the concentration of hydrogen ions. Remembering the principles of equilibrium from A-level chemistry, an equilibrium shift to the right will produce more hydrogen ions and so increase acidity – or a shift to the left will decrease the numbers of hydrogen ions and so make the system more alkaline. A shift to the right would be produced by increasing carbon dioxide or decreasing bicarbonate levels, while a shift to the left would be produced by decreasing carbon dioxide or increasing bicarbonate levels.

Anion Gap

Normal value approximately 12.
Increased gap indicates metabolic acidosis – this helps detect acidosis from a venous sample.
In metabolic acidosis, the HCO 3 - is reduced, so the concentration of other anions (either Cl - or an unmeasured anion) must increase so that an excess positive charge does not accumulate. The anion gap effectively measures these other anions, so an increase indicates metabolic acidosis – this is referred to as high anion gap metabolic acidosis, or HAGMA. It can be caused by:
Ketoacidosis, lactic acidosis, chronic renal failure, salicylate poisoning, methanol poisoning, ethylene glycol poisoning.
If it is Cl - that increases, then the anion gap will not rise – this is known as normal anion gap metabolic acidosis, or NAGMA. Causes include:
Diarrhoea, renal tubular acidosis, acetazolamide use (carbonic anhydrase inhibitor)

Body Defences Against Acid-Base Imbalance

1. 1. The chemical acid-base buffer system – this acts more or less immediately as it is essentially a chemical reaction and compensates for minor changes by locking up hydrogen ions – however it cannot add or remove hydrogen ions from the body.
2. 2. The respiratory system – this acts within minutes to eliminate CO 2 or allow it to accumulate. (CO 2 combines with water to form H 2 CO 3 , an acid)
3. 3. The kidneys – these can eliminate excess acid or base from the body, but act much more slowly (over hours to days).

Renal Function>>> Acute Renal Failure

Indicated by a sudden rise in blood urea (uraemia) and creatinine (blood-urea nitrogen). Often accompanied by oliguria (production of <15ml/hr urine) or anuria (lack of urine production), although occasionally high-output renal failure may occur. Acute renal failure is potentially reversible
Acute renal failure may be prerenal (lack of adequate blood supply), intrarenal (lack of functioning kidney tubules) or postrenal (blockage in urinary tract).

 

 

Investigation

Abnormal kidney function indicates intrarenal failure.

Sodium

Is the kidney still able to conserve Sodium? Calculate the fractional excretion of Sodium.

This tells you how much sodium is lost in the urine – a healthy kidney can resorb at least 99% of sodium, so the F E NA % should be less than 1%.
If it is higher, this indicates abnormal renal function (i.e. intrarenal failure).

Renal Concentrating Ability

Can the kidney appropriately concentrate urine? i.e. produce urine of an appropriate concentration compared to the plasma osmolality.
Calculate the ratio of urine:plasma osmolality (U/P Osmolality).
It should be >1.3:1

• A high Urine to Plasma ratio indicates the kidney still has some function.
• A low Urine to Plasma ratio indicates the kidney is not working.

Nitrogen Clearance

Are the kidneys able to get rid of urea and creatinine? Test the ratios of urea and creatinine in the urine compared to that of urine in the blood:

• Urine:Plasma UREA ratio (U/P Urea)
• Urine:Plasma CREATININE ratio (U/P Creatinine)

Both of these should be >20:1
If it is lower than this, this indicates abnormal function.

urine Sediment

Cell debris, red cells, casts etc. are a sign of intra-renal failure.

Summary

Signs of intra-renal failure.

Urine Na+ mmol/l	>20
Fractional excretion of Na (%)	>1
Urine Cl- mmol/l	>20
Urine/plasma osmolality ratio	<1.3
Urine/plasma urea ratio	<14
Urine/plasma creatinine	<14
Urine sediment	Cell debris, red cells, casts etc

Acute renal failure

types, pathophysiology, diagnosis and treatment

Divided into three main types: 

Pre-Renal Renal failure

(aka pre-renal impairment, pre-renal uraemia (PRU))
Caused by decreased perfusion of the kidneys due to extrarenal circulatory factors, e.g. hypotension, volume depletion secondary to haemorrhage or dehydration, heart failure or ACE inhibitors.

Common causes:
Extracellular Volume (ECV) Depletion: Haemorrhage, Burns, GI loss (vomiting, diarrhoea), Renal loss (osmotic diuretics, Addison's disease)

Normal or increased ECV with ineffective intravascular volume: Shock, Congestive cardiac failure, Third space fluid loss (pancreatitis, ascites, crush injury), ACE Inhibitors

Urine sodium concentration is very low (less than 20 mmol/l) and urine osmolality is high indicating that the tubules are functioning normally. Oliguria or anuria in this condition is usually of only a few hours' duration if treated aggressively - prerenal failure is readily reversible when the extrarenal circulatory disturbance is corrected, because there is no intrinsic abnormality in the kidneys. Failure to correct the prerenal causes will go on to result in intrarenal failure. (Decrease in BP to give ischaemia and death of tubules.)

Intra-renal renal failure

(aka acute renal failure, renal impairment, intra-renal impairment; intrinsic renal failure sometimes called ATN – acute tubular necrosis).
Variety of causes:

a) Ischaemic Any of the causes of pre-renal failure can lead to ischaemic ("hypotensive") acute renal failure if the defect in renal perfusion is too severe or prolonged. Renal failure persists after the extrarenal circulatory disturbance is corrected and may not resolve for several weeks. Urine sodium concentration is usually greater than 20 mmol/l and urine osmolality is low because of abnormalities in tubular function. This type of renal failure is often called "acute tubular necrosis" - a poor term to use as necrotic tubular epithelial cells are usually not apparent histologically although individual tubular epithelial cells may be missing. Recovery may take several weeks. Patients require dialysis.
b) Nephrotoxic Various pharmacologic agents and poisons (such as antibiotics (gentamicin), analgesics (paracetamol), carbon tetrachloride (CCl 4 ) can produce nephrotoxic acute renal failure which is clinically very similar to ischaemic acute renal failure but is associated with much more obvious damage to renal tubular epithelium histologically. Widespread frank necrosis of tubular epithelium is observed, particularly in the proximal convoluted tubules, so the term "acute tubular necrosis” (ATN) is more appropriate here.
Besides ischaemic and nephrotoxic acute renal failure there are a number of other less common renal parenchymal diseases which cause acute renal failure. These often have atypical clinical features, such as the presence of, haematuria, complete anuria, or signs of systemic disease. Examination of the urine sediment and, in selected cases, renal biopsy can be helpful in diagnosing these atypical forms of intrarenal acute renal failure.
c) Acute glomerulonephritis immune complex deposition may result in the destruction of the glomerular membrane e.g. Streptococcal infections and Goodpastures Syndrome.
d) Cortical Necrosis. This condition may be found in pregnant women who have abruptio placentae ("concealed accidental haemorrhage"). It is also found in the haemolytic uraemic syndrome (HUS), and in gram-negative septicaemia. It differs from ischaemic or nephrotoxic acute renal failure in that all elements of the cortex become necrotic, including the glomeruli. Recovery may take place.
e) Obstruction of Major Vessels. Acute renal failure may be produced by embolisation of a main renal artery, involvement of the larger intrarenal arteries by polyarteritis, or by sudden thrombosis of renal veins. Extensive tissue death occurs since the blood supply is cut off.
TREATMENT Maintain support of all the systems - fluid, acid base balance, infection (the patient will most likely require dialysis) until tubular regeneration occurs, usually after 3 weeks.

Post-Renal Acute Renal Failure

Caused by obstruction of the urinary tract. (eg. by tumour, stone, prostatic hypertrophy, blood clots.) Often results in complete anuria. The backpressure may cause a temporary defect in renal concentrating ability after relief of obstruction (post-obstructive nephropathy), but permanent renal damage only results from chronic obstruction.

Pseudogout - 10 Things You Should Know .........From Early Symptoms to Disease Management

Pseudogout is a type of arthritis that is often mistaken for gout or other arthritic conditions. Proper diagnosis of pseudogout is important. Untreated pseudogout can result in severe joint degeneration, chronic inflammation, and chronic disability. Here are 10 facts you should know about pseudogout.

1 - Pseudogout, as its name suggests is similar to gout, but the two conditions are caused by the deposition of different crystals.

Pseudogout is a condition that develops when calcium pyrophosphate crystals accumulate in a joint and the tissues that surround the affected joint. Gout, however, develops when uric acid crystals are deposited in an affected joint.

2 - Pseudogout, also known as CPPD disease, can mimic gout, osteoarthritis, and rheumatoid arthritis.

About 25 percent of people with calcium pyrophosphate dehydrate deposition (CPPD) disease develop what is referred to as pseudogout. About 5 percent of patients develop symptoms that more closely resemble rheumatoid arthritis while approximately 50 percent of patients with CPPD deposition develop symptoms that are like osteoarthritis. Not everyone with CPPD is symptomatic though.

3 - Pseudogout typically develops in one joint and the onset is usually sudden and intense.

A pseudogout attack may be as severe as an acute gout attack but typically it is less painful. Pseudogout attacks:

• usually last anywhere from several days to two weeks
• may be accompanied by fever
• occur spontaneously or can be brought on by severe illness, surgery, or trauma
• cause cartilage and joint damage that worsens after years of attacks

4 - Nearly half of all pseudogout attacks occur in the knee.

While the knee is the most common site for pseudogout, the big toe is most commonly affected by gout. Pseudogout can develop in any joint however, including the big toe.

5 - Anyone can develop pseudogout but the risk increases significantly with age.

The crystal deposits associated with pseudogout affect about 3 percent of people in their 60s. The percentage increases to about 50 percent of people in their 90s. The condition is equally prevalent among women and men.

6 - A small number of people with CPPD crystal deposition disease inherited susceptibility to the condition.

Aside from having a genetic predisposition to pseudogout, the risk of developing the condition is increased if the patient has any of the following metabolic disorders:

• hyperparathyroidism
• hemochromatosis
• hypothyroidism
• amyloidosis
• hypomagnesemia
• hypophosphatasia

7 - The most significant diagnostic test for determining pseudogout is a joint fluid examination.

Joint fluid is drawn from the affected joint and examined for rod-shaped or rhomboid-shaped CPPD crystals. Based on the observation of these crystals the diagnosis can be confirmed. X-ray evidence also supports the diagnosis when chondrocalcinosis (joint cartilage calcified and calcium deposits in joint spaces) is detected. If needed, other lab tests can be performed to rule out other types of arthritis.

8 - There is no cure for pseudogout but there are treatment options for controlling symptoms.

Medications are used to treat symptoms associated with pseudogout. Nonsteroidal anti-inflammatory (NSAIDs) are usually prescribed to control pain and inflammation during pseudogout attacks. For the purpose of preventing further attacks, low doses of colchicine and NSAIDs are typically prescribed. Cortisone shots into the affected joint may be another option for controlling pain and inflammation -- especially for patients who cannot use the other medications. Surgery is also an option for severely damaged joints.

9 - Because pseudogout is considered a misunderstood form of arthritis, it's important to be evaluated by a specialist.

Since pseudogout has characteristics that are similar to other types of arthritis, it's important to be diagnosed by a rheumatologist (a specialist in arthritis and related rheumatic diseases). Early, accurate diagnosis may prevent severe joint damage in some cases.

10 - Diet does not affect the onset or development of pseudogout. A change in diet cannot control symptoms.

Though the crystals associated with pseudogout are partly calcium, it is a myth that eating a lot of foods that contain calcium provoke the development of pseudogout.

HEMORRHOIDS AND WHAT TO DO ABOUT THEM.................. A few simple strategies can help ease the pain and trouble associated with these bothersome bulging blood vessels.

Many women have a passing encounter with hemorrhoids during pregnancy. But by midlife, hemorrhoids often become an ongoing complaint. By age 50, about half the population has experienced one or more of the classic symptoms, which include rectal pain, itching, bleeding, and possibly prolapse (hemorrhoids that protrude through the anal canal). Although hemorrhoids are rarely dangerous, they can be a recurrent and painful intrusion. Fortunately, there’s a lot we can do about them.

What are hemorrhoids?

In one sense, everyone has hemorrhoids, the pillow-like clusters of veins that lie just beneath the mucous membranes lining the lowest part of the rectum and the anus. The condition most of us call hemorrhoids (or piles) develops when those veins become swollen and distended, like varicose veins in the legs. Because the blood vessels involved must continually battle gravity to get blood back up to the heart, some people believe hemorrhoids are part of the price we pay for being upright creatures.

There are two kinds of hemorrhoids: internal ones, which occur in the lower rectum, and external hemorrhoids, which develop under the skin around the anus. External hemorrhoids are the most uncomfortable, because the overlying skin becomes irritated and erodes. If a blood clot forms inside an external hemorrhoid, the pain can be sudden and severe. You might feel or see a lump around the anus. The clot usually dissolves, leaving excess skin (a skin tag), which may itch or become irritated.

Internal hemorrhoids are typically painless, even when they produce bleeding. You might, for example, see bright red blood on the toilet paper or dripping into the toilet bowl. Internal hemorrhoids may also prolapse, or extend beyond the anus, causing several potential problems. When a hemorrhoid protrudes, it can collect small amounts of mucus and microscopic stool particles that may cause an irritation called pruritus ani. Wiping constantly to try to relieve the itching can worsen the problem. 

Anatomy of hemorrhoids

Hemorrhoids are distended blood vessels that form either externally (around the anus) or internally (in the lower rectum).

What causes hemorrhoids?

Experts are divided on exactly what causes hemorrhoids, but probably several mechanisms are at work. Traditionally, hemorrhoids are associated with chronic constipation, straining during bowel movements, and prolonged sitting on the toilet — all of which interfere with blood flow to and from the area, causing it to pool and enlarge the vessels. This also explains why hemorrhoids are common during pregnancy, when the enlarging uterus presses on the veins.

More recent studies show that patients with hemorrhoids tend to have a higher resting anal canal tone — that is, the smooth muscle of the anal canal tends to be tighter than average (even when not straining). Constipation adds to these troubles, because straining during a bowel movement increases pressure in the anal canal and pushes the hemorrhoids against the sphincter muscle. Finally, the connective tissues that support and hold hemorrhoids in place can weaken with age, causing hemorrhoids to bulge and prolapse.

Diagnosing hemorrhoids

Hemorrhoids can usually be diagnosed from a simple medical history and physical exam. External hemorrhoids are generally apparent, especially if a blood clot has formed. Your clinician may perform a digital rectal exam to check for blood in the stool. She or he may also examine the anal canal with an anoscope, a short plastic tube inserted into the rectum with illumination. If there’s evidence of rectal bleeding or microscopic blood in the stool, flexible sigmoidoscopy or colonoscopy may be performed to rule out other causes of bleeding, such as colorectal polyps or cancer, especially in women over age 50.

Home treatment

Most hemorrhoid symptoms improve dramatically with simple, at-home measures. To avoid occasional flare-ups, try the following.

Get more fiber. Add more fiber to your diet from food, a fiber supplement (such as Metamucil, Citrucel, or Fiber Con), or both. Along with adequate fluid, fiber softens stools and makes them easier to pass, reducing pressure on hemorrhoids. High-fiber foods include broccoli, beans, wheat and oat bran, whole-grain foods, and fresh fruit. Fiber supplements help decrease hemorrhoidal bleeding, inflammation, and enlargement. They may also reduce irritation from small bits of stool that are trapped around the blood vessels. Some women find that boosting fiber causes bloating or gas. Start slowly, and gradually increase your intake to 25–30 grams of fiber per day. Also, increase your fluid intake.

Exercise. Moderate aerobic exercise, such as brisk walking 20–30 minutes a day, can help stimulate bowel function.

Take time. When you feel the urge to defecate, go to the bathroom immediately; don’t wait until a more convenient time. Stool can back up, leading to increased pressure and straining. Also, schedule a set time each day, such as after a meal, to sit on the toilet for a few minutes. This can help you establish a regular bowel habit.

Sitz. A sitz bath is a warm water bath for the buttocks and hips (the name comes from the German “sitzen,” meaning “to sit”). It can relieve itching, irritation, and spasms of the sphincter muscle. Pharmacies sell small plastic tubs that fit over a toilet seat, or you can sit in a regular bathtub with a few inches of warm water. Most experts recommend a 20-minute sitz bath after each bowel movement and two or three times a day in addition. Take care to gently pat the anal area dry afterward; do not rub or wipe hard. You can also use a hair dryer to dry the area.

Seek topical relief. Over-the-counter hemorrhoid creams containing a local anesthetic can temporarily soothe pain. Creams and suppositories containing hydrocortisone are also effective, but don’t use them for more than a week at a time, because they can cause the skin to atrophy. Witch hazel wipes (Tucks) are soothing and have no harmfu l effects. A small ice pack placed against the anal area for a few minutes can also help reduce pain and swelling. Finally, sitting on a cushion rather than a hard surface helps reduce the swelling of existing hemorrhoids and prevents the formation of new ones.

Treat the clot. When an external hemorrhoid forms a blood clot, the pain can be excruciating. If the clot has been present for longer than two days, apply home treatments for the symptoms while waiting for it to go away on its own. If the clot is more recent, the hemorrhoid can be surgically removed or the clot withdrawn from the vein in a minor office procedure performed by a surgeon.

Rubber band ligation To perform a rubber band ligation, the clinician places a ligator over the hemorrhoid to position a rubber band around its base.

Procedures to treat hemorrhoids

Some hemorrhoids can’t be managed with conservative treatments alone, either because symptoms persist or because an internal hemorrhoid has prolapsed. Fortunately, a number of minimally invasive treatments are available that are less painful than traditional hemorrhoid removal (hemorrhoidectomy) and allow a quicker recovery. These procedures are generally performed in a surgeon’s office or as outpatient surgery in a hospital.

Band it. The most commonly used hemorrhoid procedure in the United States is rubber band ligation, in which a small elastic band is placed around the base of a hemorrhoid (see bow above). The band causes the hemorrhoid to shrink and the surrounding tissue to scar as it heals, holding the hemorrhoid in place. It takes two to four procedures, done six to eight weeks apart, to completely eliminate the hemorrhoid. Complications, which are rare, include mild pain or tightness (usually relieved with a sitz bath), bleeding, and infection. Other office procedures include laser or infrared coagulation, sclerotherapy, and cryosurgery. They all work on the same principle as rubber band ligation but are not quite as effective in preventing recurrence. Side effects and recurrence vary with the procedure, so consult your physician about what’s best for your situation.

Hemorrhoidectomy. You may need surgery if you have large protruding hemorrhoids, persistently symptomatic external hemorrhoids, or internal hemorrhoids that return despite rubber band ligation. In a traditional hemorrhoidectomy, a narrow incision is made around both external and internal hemorrhoid tissue and the offending blood vessels are removed. This procedure cures 95% of cases and has a low complication rate — plus a well-deserved reputation for being painful. The procedure doesn’t involve an overnight hospital stay, but it does require general anesthesia, and most patients need narcotic analgesics afterward. Patients can usually return to work after 7–10 days. Despite the drawbacks, many people are pleased to have a definitive solution to their hemorrhoids.

Staples. A newer alternative to traditional hemorrhoidectomy is called stapled hemorrhoidopexy. This procedure treats bleeding or prolapsed internal hemorrhoids. The surgeon uses a stapling device to anchor the hemorrhoids in their normal position. Like traditional hemorrhoid removal, stapled hemorrhoidopexy is performed under general anesthesia as day surgery, but it’s less painful and recovery is quicker. It’s more painful than rubber band ligation and has more minor side effects, but it only needs to be done once; the hemorrhoids are also much less likely to return. Research is now under way comparing stapled hemorrhoidopexy with rubber band ligation and hemorrhoidectomy as a first-line treatment for internal hemorrhoids.