Symptoms

The symptoms depend on the location of the complaint.

When should you consult a doctor?

When you have problems from the abnormality and when it itches, grows or bleeds, or just if you're concerned about your condition.

Most marks on the skin and lumps are innocent. It is still sensible to regularly check your skin. This is especially important if your skin is regularly exposed to the sun.

Investigation and diagnosis

It's not always possible to see with the naked eye if a skin abnormality is malignant. In some situations a dermatologist can use 'non-invasive' techniques to determine this. If there is still doubt it is advisable for a surgeon to remove the abnormality so that it can be pathologically tested under the microscope.

Treatment

Treatment nearly always relies on local anaesthetic. This is achieved with the help of one or more injections around the area to be treated. The anaesthetic lasts between 30 and 60 minutes. You can usually go home almost immediately after the treatment.

What preparations can you make for the operation with local anaesthesia?

• Tell the doctor if you are using any medicines or have any allergies (for example to plasters, iodine etc.)
• The part of the body on which the operation will take place should be washed well before you come to the hospital.
• Your nails should be short, clean and free of nail varnish.
• Wear loose clothing, so there is room for a bandage.
• You can eat and drink normally before the operation.
• Leave your jewellery at home.
• Depending on the anaesthetic, and also the operation, you will receive advice about whether (for example) you can drive home.

When should you consult a doctor?

Go to a doctor when the swelling gives you a lot of problems, becomes larger inspite of treatment, lasts longer then 2 days, a red stripe spreads along your arm or leg from the original abnormality, you have a temperature (higher than 38° Celsius), you have a dramatically fluctuating temperature or you feel sick.

Symptoms

The symptoms that go with inflammation of the skin, fingers, hand or nails are redness, pain, heat and swelling. A temperature only occurs when the inflamed area is large or when bacteria get into the blood stream. Fluctuating temperature (an occasionally very high temperature sometimes accompanied by shivering) occurs especially with abscesses.

When you see a red stripe spreading along an arm or leg from the original abnormality in the direction of the body this can mean that the infection has spread to a blood vessel which lies just under the skin (flebitis).

With a large infection or abscess you may feel very sick.

Preventing inflammation after getting a wound

• Clean the wound with a disinfectant liquid. Then dress it with a breathable plaster or bandage. Sometimes a wound needs to be cleaned surgically.
• Always go to a doctor if you've been bitten by an animal or a person. Antibiotics are need to prevent troublesome inflammation.
• Inoculation against tetanus is required with bite wounds and wounds caused by dirty objects. Check with your doctor whether you´ve already been immunised.

In England when you first discover an abnormality in the breast you go to a GP. The doctor refers you to a surgeon if more research is needed or there is a possible need for treatment. In Spain a gynaecologist is usually responsible for breast check-ups. Treatment is by a gynaecologist or surgeon.

Self examination of the breast

It is tricky to effectively examine your own breasts, especially as you are looking for something that you don't want to find. But when you examine regularly you learn how your breasts feel and what is normal. If you find it difficult, you can of course ask a doctor to check for you. In this case try to go regularly to the same doctor.

The best time to look is one week after menstruation. If you no longer menstruate try to do an examination regularly on the same day each month.

In Spain the gynaecologists rely mostly on a physical examination and an x-ray if necessary or if you are over 40.

National population-based screening programme for breastcancer

In Spain there is no government financed screening program for breastcancer. The gynaecologist usually does the general check up. Women who do not have any risk factors are generally advised to get a mammography every 1 or 2 years if they are older than 40. Go to Medical links (prevention and early detection of cancer) for more information about national guidelines concerning screening on cancer.

When should you go to a doctor?

You should see a doctor when you discover a lump in your breast that wasn't there before, or which feels at all unusual. But also when there are depressions or dimples in the breast; the nipple pulls back into the breast in a way that hasn't occurred before; there are other changes in the nipple such as redness, flaky skin or fluid comes out (this could be watery, milky, green or bloody); you have pain in the breast in a place where the gland tissue feels unusual; the breast feels hot and red; or when you have a skin ulcer that won't heal.

Symptoms

Most lumps give no clear symptoms. Sometimes they're painful or give a feeling of numbness. Bleeding may occur from the nipple.

Investigation and diagnosis

If a problem is found during a physical examination, further research is done. An ultrasound, a mammograph (x-ray of the breast) and a biopsy are normal. With a biopsy, cells are extracted from the abnormal tissue with a needle, in order to do further research under the microscope.

Treatment

Treatment depends on the diagnosis. Benign abnormalities that give a lot of discomfort can be surgically removed. Sometime this can be done with a local anaesthetic but mostly it is best for patients to have a full anaesthetic.

Breast cancer is best treated by a surgeon or gynaecologist who specialises in this area working in a multidisciplinary team.

What is a hernia?

The abdominal wall consists of a strong layer of muscle and sheets of tendon which ensures that the abdominal organs stay in place. On the inside, in the abdomen, the wall is lined with peritoneum. There are a number of openings in the abdominal wall to allow structures 'through'. This occurs for example during the growth of an unborn male baby when the testicles move from inside the belly to outside. The channel that then exists is called the groin channel.

A hernia normally occurs in one of these weaker places. The peritoneum bulges through the opening, sometimes including parts of abdominal organs, outside the wall. A hernia can already be present at birth, but it can also develop in older age. This can arise through an increase in pressure in the belly resulting from heavy lifting, or strain during a bowel movement or through coughing. When the abdominal wall stretches as the result of an increase in body weight, vulnerable points become weaker and existing hernias often become bigger.

When should you go to a doctor?

Having a hernia doesn't necessarily mean that you will have to undergo an operation. It is still sensible to consult a doctor if you have discovered a swelling. When you (or your child) has a swelling that is painful and doesn't go away when you push on it gently or if you (or your child) are also sick, consult a doctor immediately.

Symptoms

An uncomplicated hernia is usually painless. If the hernia is large and located in the groin, it can give pain when sitting or when bending the legs. The hernia usually disappears if you lie flat, or push softly against it with your fingers.

Investigation and diagnosis

A physical investigation is usually sufficient to establish a diagnosis. Sometimes an ultrasound is made. For unusual hernias further investigation is required.

When to operate?

The most common reason for operating is if a hernia becomes jammed. A piece of tissue is jammed in the abdominal wall opening. If the hernia is not pushed back in within 24 hours of the blockage (which should only be done by a doctor!) it can become necessary to operate.

Treatment of hernias

Different hernias are operated on in different ways. An 'open' method may be used involving an incision in the skin above the swelling, then the abdominal wall is reinforced by integration of artificial material. A laparoscopy may be appropriate to achieve the same ends, but this is not used as standard.

The condition is a treated with a (laparoscopic) Nissen fundoplication and is conducted by my Spanish colleagues.

When should you consult a doctor?

If you suffer a burning feeling especially after eating or lying down, then you should first go to a gastro-enterologist (possibly via your GP). From here you will be referred for an operation if that is necessary.

Investigation and diagnosis

Extensive investigation is usually necessary if you have heart burn. A blood test and/or a gastroscopy (where a camera on a flexible stalk is used to look in your stomach) is usually the first investigation that is done. An ultrasound of the gallbladder reveals the presence of gallstones (GER symptoms can be similar to those that occur with gallstones).

If there is a suspicion of a hernia in the diaphragm an x-ray of the oesophagus is made after you have drunk a fluid to enhance the contrast of the image. An acid and/or pressure measurement is also often taken in the oesophagus before the operation.

The operation

The Nissen fundoplication is almost always conducted laparoscopically. A new mechanism is made to ensure the uppermost entrance of the stomach can be properly closed.

When should you go to a doctor?

Abdominal pain can be caused by many different things. Some are harmless, but others may be serious or even life threatening.

When you suffer a sudden onset of abdominal pain that is coupled with feeling faint, unwell or sick, diarrhoea, blood loss or high temperature it is sensible to consult a GP or a doctor in a hospital. From there you can make contact with me.

Symptoms

Abdominal pain can be nagging, cutting or cramp like. It can be permanently present or come in attacks. It can force you to stay still, or to move.

The location of the pain is not always the location of the problem. You may suffer shoulder pain as a result of a problem located in the abdomen. Children often complain about abdominal pain when infact there's something else that's the matter. Normally there are also symptoms of feeling and actually being sick, diarrhoea, constipation and temperature.

Investigation and diagnosis

A physical examination is always necessary when you consult a doctor about abdominal pain. Depending on the possible causes further investigations will be conducted such as blood tests, an x-ray or ultrasound or a computerized scan of the abdomen. These are done in the hospital.

When to operate?

If it's necessary to operate, the reasons why will be explained to you. Because there are so many possible causes it is not possible to go into more detail here.

The operation

Abdominal operations are usually major and always take place under general anaesthetic. In most cases you'll have to spend a number of days in the hospital.

There are 2 techniques:

Laparotomy (open abdominal operation)

The operation is conducted via an incision in the abdominal wall either in the midline (usually vertically) or in the left or right upper or lower quadrant of the abdomen (usually horizontally). The incision is stitched closed in layers at the end of the operation.

Laparoscopy (´key-hole´ surgery)

The operation is conducted with a camera in conjunction with other instruments. These are inserted through small incisions in the abdomen. Many abdominal operations can be done using this method. Gallbladder operations almost always use this technique. Sometimes it's necessary to convert to an open technique. Patients generally make a faster recovery after a laparoscopic operation.

Causes

Itching can occur as a result of a skin complaint around the anus, this can result from irritation of the skin as a result of the loss of mucus from the anus or a small hole outside, or through the eggs of ringworms.

Pain can result from piles (hemorrhoids), a sore in the anus (anal fissure), a perianal fistula or an infection (perianal abscess, proctitis).

Blood loss can result from an anal fissure, a bleeding hemorrhoid, inflammation of the intestine or through a polyp or a tumor.

Mucus or fluid loss via the anus can be caused through an inflammation of the intestine or a perianal fistula.

Incontinence via the anus occurs more in women than in men mainly due to pregnancy and delivery. The muscles of the pelvic floor become weaker and the anal sphincter becomes loose or even damaged. Occasionally a partial prolapse of the vaginawall, the womb (uterus), the urine bladder or the rectum can develop. The resulting complaints such as incontinence are mostly temporarily. However, it is advisable to do exercises to strengthen your pelvic floor not only in the period directly following the birth of your child, but also later. A simple exercise is ´the lift´: contract your muscles gradually as if you were in a lift going to the 4th floor. It stops shortly at every floor. Relax in the same manner as if you were going down with the lift.

You can find information about these conditions in the following sections (the first is an external website).

• Condylomata accuminata (genital warts)
• Anal fissure (sore in the anus)
• Hemorrhoids (piles)
• Perianal fistula

Symptoms

An anal fissure usually gives a sharp pain after defecation, sometimes with minor loss of blood.

Investigation and diagnosis

Usually the complaints are typical of those of an anal fissure and physical examination alone is sufficient to establish the diagnosis. To detect the existence of a fissure the anus is gently spread with the fingers. If blood loss persists after treatment of the fissure, internal (endoscopic) examination of the rectum should be conducted to exclude other causes.

Treatment

Generally the anal fissure is easily treated by simple measures in order to keep your stools smooth and soft. Try to eat at regular times, eat food rich in fibers and drink sufficient water (1½ liter a day). It is important to take your time when going to the toilet. If these measures do not help to soften your stools, medicine can be taken. Depending on the severity of your complaints one of the following treatments will be advised if your complaints do persist.

Ointment with isosorbidedinitrate (ISDN)

This is the treatment of choice. The active ingredient in this ointment is a blood vessel dilator. Apply the ointment every 4 to 6 hours on the fissure in the anus. Headache can result from using the ointment, but generally disappears after using it for 1 or 2 days. For best results continue with this treatment for 3 months. After 6 weeks progress will be assessed.

Injection with botulinus toxin

Botulinus toxin is injected in the anal sphincter. It paralyzes some muscle fibers in order to diminish the tension of the sphincter. This technique is relatively new.

Operation

The lateral internal sfincterotomy (LIS) is nowadays rarely conducted. The internal part of the sphincter is incised to diminish the tension of the sphincter. The wound is left open to minimize the risk of infection. This operation is performed under local or general anaesthetic.

What are hemorrhoids and how do they develop?

Hemorrhoids are these cushions which have become floppy. This can be due to a higher and/or more continuous pressure in the cushions as a result of pregnancy, being obstipated with hard stools or a standing profession. Hemorrhoids also tend to accompany certain diseases. If the hemorrhoids cure themselves after a long time, usually a small skin flap remains (skin tag, marisc).

Symptoms

Blood loss, itching, swelling, hygienic problems or pain can result from hemorrhoids.

How to prevent getting symptoms

• Use only soft tissue or wash the anus with water after defecation.
• Do not use soap, this can cause itching or irritation.
• Keep your stools smooth and soft by:
• eating at regular times
• eating sufficient fibers (bread etc.)
• drink at least 1½ liter water a day
• do physical exercise
• Go to the toilet at regular times and take your time. It is unwise to retain your stools.
• Take a rest during the last weeks of your pregnancy, this also allows you to diminish pressure on your pelvic floor.

Investigation and diagnosis

Typical symptoms lead easily to the diagnosis. If blood loss persists despite simple measures, endoscopic examination of the rectum and or colon is required.

Treatment

Most patients are cured by following the measures mentioned above. In case of bulging hemorrhoids taking a bath can relieve your complaints.Your pharmacy can provide a number of ointments and suppositories without a prescription. Once the diagnosis has been established, treatment of the hemorrhoids should only take place if the complaints bother you.

Treatments on the outpatient's clinic and without anesthesia:

Rubberband ligation

The hemorrhoid is lifted. Just above the hemorrhoid a small balloon of tissue is sucked into a suction device. A rubber band is placed on the stalk of the tissue balloon.

Sclerosing

A sclerosing fluid is injected in the hemorrhoid in order to let it shrivel. This treatment is not often done.

Treatments with anesthesia (local, regional or general):

Marisectomy (excision of a skin tag or marisc)

The skin flap is excised after local anesthesia. The wound is left open.

Hemorrhoidectomy (Milligan-Morgan)

The hemorrhoids are excised surgically. Sometimes the wounds are left open.

Circular hemorrhoidopexy (Longo-procedure)

With a circular stapler the mucous membrane, inside the rectum just above the anus is lifted.

Symptoms

There is usually loss of pus or fluid out of a small hole just outside the anus. It can look like a pustule.

Diagnosis

For simple fistulas physical examination alone is sufficient to establish the diagnosis. For more complicated fistulas usually an endo-ultrasound or MRI is done to map out the course of the fistula in order to plan the appropriate operation.

Treatment

Whether a fistula should be treated at all, depends on the severity of the complaints. Sometimes they are less annoying than the possible consequences of an operation.

Treatments with anesthesia (local, regional or general):

Seton

A seton is a thread or a small tube introduced in the fistula. The end is knotted to prevent it falling out. The seton can be left in place for months. Complicated fistulas can be treated this way, because the sphincter is preserved.

Tissue-col

This is a glue introduced in the fistula to seal the canal.

Fistulotomy

The canal is opened all the way long. The wound is left open and closes itself within a couple of weeks.

Fistulectomy

The canal of a fistula is lined with tissue which prevents it from collapsing and sealing. This tissue is scraped out.

Mucosa advancement plasty

The internal opening of the canal is closed. After closure it is covered by a vascularized small flap of mucous membrane.

What is overweight?

We speak of overweight when the body-mass index (BMI) is higher than 30kg/m². If the index is more than 40 kg/m² this is described as pathologically overweight. The body-mass is calculated by dividing body mass in kg by height in meters squared (multiplied by itself).

Risks associated with being overweight

Being overweight increases the chance of high blood pressure, heart and vascular diseases, diabetes and complaints of overloading your articulations.

Investigation and diagnosis

Investigation focuses on identifying diseases which can cause overweight problems such as a drop in the activity of the thyroid gland and Cushing's syndrome. Diseases that can result from being overweight are also investigated.

What can you do about it yourself?

You've probably tried everything, but here are a few tips which may prove helpful. Think about how much you want to lose weight. How important is it for you? How important is it for your health?

• Write down what you eat each day, keep the diary going for 2 weeks. Then consider what you can cut out of your diet.
• Try to avoid excessively fat (chocolate, chips, crisps etc), sweet (cola, sweets etc) and calorific (milkshake, peanuts, beer etc) foods.
• Reduce first the size of your meals, and only later the frequency. In this way you can reduce the size of your stomach without resorting to an operation, though this is a process that may last several months.
• Physical exercise accelerates the process.
• If you have an irresistible desire to eat something, drink a glass of water, or eat something rich in fiber which will fill you up, try raisin bread or rye bread or vegetables (cauliflower, carrots etc).
• Don't intend to never eat again. And also don't go through the whole day without food. That usually means that you end up eating more in the evening and you won't succeed in losing weight.
• Try to determine your eating pattern so you have an appetite in the morning and can eat a proper breakfast. This means that you should not eat late in the evening or at night.
• Try to find an occupation which distracts your attention from thinking about eating or not-eating. If you can distract yourself it may prove helpful in achieving your goal.

Thus the best manner to lose weight is to change your lifestyle. In general this requires guidance from a professional. The more motivated you are, the better the chances of success.

When should you be treated?

Morbid obesity must be treated because it can be life threatening. Medicines exist, but once it's been determined that you should be treated then usually an operation is more effective. But every operation has risks and there is a significant chance that after the operation you will still suffer frustrating symptoms.

When would you be considered for an operation?

If you have (a) a BMI of more than 40 kg/m², or (b) a BMI between 35 and 40 kg/m² along with a number of sicknesses associated with morbid obesity which make a normal life impossible. Before any operation a team of professionals will decide if it is appropriate.

Operation

The various techniques can in principle all be conducted using laparoscopic techniques. A stomach reduction (vertical gastroplasty and gastric banding), a bypass (from biliopancreatico or duodenal switch) that addresses malabsorption (insufficient uptake of foodstuffs) or a combination of both (bypass of the stomach). The appropriate operation is determined by a team of professionals.

A detailed description of the scope of the operations is beyond the scope of this site. In these illustrations you can see 2 different techniques.

Stomach bypass (laparoscopic): 80% stomach reduction, 20% malabsorption.

Duodenal switch (laparoscopic): 100% malabsorption.