When appropriate information on an important health problem is absent or inadequate, awareness is low, but paradoxically, many people will be seen making suggestions and giving instructions ,some of which may confuse and confine an affected person. Safe and sound information on specific matters therefore need to be reinforced for certain categories of people where resistance to change is either expected or becomes a barrier to effective mobilization. Beyond these, awareness may be high but additional problems arise and create hurdles such that nothing of what the individual knows ever translates to knowledge and the willingness to seek medical help . The results include low perception of health risks, inaction, indecision, wrong decision and at times paranoia .And so ,particularly in the rural communities, it is really difficult to get people to believe that the way we live , our occupation, the type of food we eat and drink , our genetic constitution, age , gender among others can lead us to develop stones; real stones of different shapes, colour composition and sizes in the kidneys and the gall bladder
In situations where good medical advice is not available, where reasonable medical advice is offered free of charge, but promptly ignored, for reasons of poverty, culture, religion/faith or paranoia, the alternatives are frequently disastrous . This does not mean there are no alternative solutions, but in some certain cases, these alternatives simply lead onto the paths of no return. Stones do arise in the kidneys and they have in many patients precipitated kidney failure and death. They also develop in the gall bladder, giving rise to many other very dangerous disease conditions that eventually lead to liver failure, failure of the pancreas, failure of the heart and many other organs will fail(multiple organ failure). This much has been discussed earlier. This week concludes the matter by examining the treatment options in some detail
Very often, the ability and understanding to carefully pick out the many symptoms and signs that are commonly associated with stones in the kidneys or in the gall bladder tucked in under the liver, in relation to the anatomical locations of these organs in the human body determines whether an affected patient dies or lives. Where as the untrained mind may conclude that every groin swelling is a hernia, the trained physician knows from his knowledge of anatomy and his experience beginning from his days as an intern, that a groin swelling with reasonably defined characteristics in a child, will have an array of differentials different from a similar one in an adult. He will also know that the diagnostic approach to swellings in the groin in males will follow channels different from those, usually reserved for similar conditions in females. In the same way, creating myths out of disease conditions such as stones buried inside organs so deep inside the body that the pain and agony they cause can only be felt but not seen, is usually not in the province of trained physicians . Over the years, Nigerians trained as Medical Doctors here in Nigeria have demonstrated levels of professionalism and competence so thorough that they are able to give very good accounts of themselves any where in the world. They do not rely wholeheartedly on the expensive and sophisticated gadgets available elsewhere in the developed world, and yet for conditions as kidney or gall bladder stones, they are able to make definitive and reliable diagnosis, only employing such equipment as ultrasound scan for confirmation. The same can not be vouched for others in the health care delivery system; Perhaps when trainers are properly trained, the difference between different groups of care givers will be narrowed. Unfortunately, majority of the patients who go through recurrent episodes of agonizing pain from kidney or bladder stones do not go to Hospitals as soon as their problems begin. They see people who claim absolute knowledge of every thing while the patients themselves do not know what to think or believe. Some are given medicines that contain Alcohol and other herbs that cloud judgement and further harm the ability to think properly. The continue in the wilderness of uncertainties until dangerous deterioration sets in.
One major reason patients go to places other than Hospitals apart from ignorance is poverty, Governments at all levels must take full responsibility for failing to provide basic health care facilities to take care of ordinary citizens and for setting up a poorly integrated National health insurance scheme. However , what patients often fail to realize is that help is always available at the level of teaching hospitals.
As was discussed earlier, stones in these organs may be very small and so depending on the location, may not produce observable or noticeable symptoms. In other conditions, a stone may be so large that it becomes as big as the kidney or the gall bladder. A stone will always grow and could reach a size where it is able to block the path of urine passage and condemn the whole organ, or break through the wall of the gall bladder in the case of the gall bladder stone. It has to be understood however that small stones, less than 5mm can also produce severe incapacitating pain depending on the anatomical location; where in the kidney or gall bladder they are situated bladder
In general what is done about stones in these organs depends on the following;
.What was obtained from the questions asked by the Doctors and the quality of information provided; Doctors are not magicians and very often, patients make the mistake of becoming uncooperative ,particularly when they feel wrongly of course that too much time is being wasted asking too many questions
.Findings after thorough physical examination of patients
.What additional information Doctors are able to gather from laboratory and other ancillary investigations
Other issues of importance include, age, sex, gender, occupation, level of education, religion, belief ,diet, exercise, delicate physical condition such as pregnancy, presence of any other illness/medication, past illness /medication, etc
Questions will be asked as to to how the present illness developed, onset , nature, pattern and frequency of appearance and disappearance of an important symptom such as pain and response to medication .
In many situations, and under hospital conditions, a medical team will do many things at the same time , all carefully orchestrated to ensure that the patient comes out of the grief and agony well, and every one is happy. Therefore nothing will be left to chance
Following physical examination , a patient in severe persistent pain as may occur in the two conditions may die from exhaustion. He or she can also die from heart attack through the capacity of severe relentless pain to cause a jamming of the branches of the vagus nerve (CNX) to the heart. There are medicines (not propofol), administered only under the supervision of registered Physicians to STOP the pains. The results are usually quick and gratifying, such that patients have been known to proclaim miracles, though the stones remain where they are, untouched .
Stones in the kidneys or gall bladder are not infrequently associated with vomiting, which may not only result in increased pain intensity, but may even combine with other aspects of the derangement in relevant physiology of the patient to bring about, renal shut down, multiple organ failure and death. Doctors may therefore wish to administer intravenous fluids(drips)
In many cases(including one seen by the writer, where a piece of stone, L-shaped and about 3cm by 2,5cm was stuck in the fossa navicularis( small egg shaped widening ;normal anatomy of the penile urethra, just behind the opening of the male penis), elaborate management may not be necessary. In conditions like that ,the stones are removed by quick surgical procedures with or without local anaesthesia administered by injection or in the form of cream. But unlike what happens in remote places far away from city centres, the patients are not sent home but kept for further investigations and informed about the possibility of forming more stones in future
All the emergency care stated and more may be going on, while at the same time, all relevant questions are asked and it is in the best interest of the patient for who ever is providing answers to do so with maximum cooperation with the managing team of Doctors.
A Medical Doctor carrying out physical examination of the patient with stones in the kidneys or gall bladder will follow established guidelines, carefully working through the history with an open mind taking into consideration, the variables stated earlier which include, but not restricted to age, sex, gender, occupation, life style, dietary habits, drug and alcohol use, etc
LABORATORY INVESTIGATIONS
The type and number of laboratory investigations depend on the situation of the patient as at the time of reporting. Others include age, sex, occupation etc
These laboratory investigations can be divided into general and specific tests
General tests should include tests on blood, urine ,stool, and any others considered suitable at that time
Specific tests include ultrasound scan . Ultra sound scan of the abdomen and pelvis remains the cheapest imaging technique for now in the diagnosis of stones in the kidney gall bladder.
From the foregoing, it will have become clear that management of stones in the kidney or gall bladder is not what any one should play around with . These are simply specialist areas and patients should be identified as early as possible and referred as quickly as possible to centres and professionals recognized for handling of such cases with very good results
The main stay of treatment is surgery ,but not until the patient is made fit for surgery . It is left for the professionals to decide what kind of surgical intervention best applies in a particular situation.
Are there alternatives to surgical interventions? yes , but not for large stones, and certainly not for multiple small stones located in the gall bladder or in the substance of the kidney and involving the two kidneys.
Concluded