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Inflammatory bowel disease is an immune mediated chronic digestive disorder bothering individuals of almost all the age groups. It has two types; ulcerative colitis (UC) and Crohn’s disease (CD).


Common risk factors predisposing to the disease are;

  • Genetic predisposition “ being a familial disease, there is strong genetic predisposition for the causation of this disease. Monozygotic twins have 6 % concordance for ulcerative colitis and 58 % concordance for Crohn’s disease, whereas dizygotic twins have 4 % concordance for Crohn’s disease. Inflammatory bowel disease is associated with certain genetic syndromes like Turner’s syndrome which provides an additional evidence for its genetic predisposition.
  • Cigarette smoking “ there is two fold increase in Crohn’s disease where as 1.7 fold increase in ulcerative colitis.
  • Oral contraceptives
  • Appendectomy “ it increases the risk of Crohn’s disease but is protective against ulcerative colitis.

Being an autoimmune disorder, pathogenesis of inflammatory bowel disease depends on the complex interaction between the endogenous, exogenous and environmental factors leading to a chronic state of inflammation of the digestive tract.

Although classified in one group, ulcerative colitis and Crohn’s disease have few differences which I feel to mention in my discussion. Ulcerative colitis, predominantly a mucosal disease commonly involves the rectum and colon (whole or partial). In almost half of the cases, disease is limited either to rectum or sigmoid colon. Crohn’s disease is a transmural disease (involving all the layers of the wall of digestive tract) and can affect any part of the gastrointestinal tract from mouth to the anus. Both small and large intestine is involved in almost half of the patients suffering from Crohn’s disease.

Clinical presentation of any of the types of inflammatory bowel disease depends predominantly on the site involved. For detailed review of symptoms if IBD please visit;


Major symptoms of ulcerative colitis are cramping abdominal pain, diarrhea, bleeding per rectum, tenesmus and passage of mucus. Although ulcerative colitis can present acutely, however the typical form of disease is chronic. In case of proctitis (inflammation of the anal canal and rectal lining) common symptoms are passage of fresh blood or blood stained mucus, tenesmus, constipation and urgency to evacuate with a permanent feeling of incomplete evacuation. Abdominal pain is not a major symptom in case of proctitis. If disease spreads beyond the rectum and involves the colon, blood mixed with stool or grossly bloody diarrhea becomes a major feature with other symptoms like severe cramping and abdominal pain, nocturnal or postprandial diarrhea, anorexia, nausea, vomiting, fever and weight loss. Physical examination of patients of ulcerative colitis reveals tenderness in anal canal and directly over the colon (on palpation). Blood is present on rectal examination.

The symptoms of Crohn’s disease depend on the site involved;

  • Ileocolitis “ chronic history of recurrent lower abdominal pains and diarrhea. The character of pain is colicky and low grade fever is present in uncomplicated disease. Weight loss develops due to anorexia, diarrhea and fear of eating.
  • Jejunoileitis “ predominant symptoms occur due to the loss of digestive and absorptive surface of the gastrointestinal tract due to chronic inflammation of the digestive tract. Malabsorption and steatorrhea are the predominant features. Patient may present with anemia, neuropathy, Pellagra and vertebral fractures due to malnutrition.
  • Colitis and perianal disease “ common symptoms are fever of low grade type, diarrhea, cramping abdominal pain, generalized fatigue and passage of fresh blood through the anus. It affects almost 1/3rd of the patients with this disease and may cause strictures, perirectal abscesses and anorectal fistulae.

After going through the details of inflammatory bowel disease incidence and the suffering cause by this disease in the human population, it is important o discuss the management of this disease. Certain home remedies are available that may help in alleviating the symptoms of the disease.

  • Cessation of smoking “ as already discussed, smoking being a causative agent for both the Crohn’s disease and ulcerative colitis must be quitted.
  • Diet “ although no specific diet is available for the prevention of this disease, however changing dietary habits can help in relieving the symptoms of inflammatory bowel disease.
    • Try eating small multiple meals instead of two or three heavy meals.
    • Drink enough fluids “ water should be preferred over all the fluids as it is best for the gastrointestinal tract. Caffeine containing fluids are not recommended as they can make the diarrhea worse.
    • Fiber intake “ although fiber is the best part of the diet but it should be avoided in the patients with inflammatory bowel disease because it may worsen the diarrhea
  • Mental and emotional stress and strain “ it is one of the most important factor influencing the normal function of gastrointestinal tract. Stress can be acute or chronic and it is almost impossible to avoid the stress in our lives. Still we must find means and ways to lessen or reduce the stress by taking exercise regularly, hypnosis and breathing and relaxation exercises.

Home remedies are not sufficient to halt the disease process of the inflammatory bowel disease and for that certain drugs are used either alone or in combination to alleviate the symptoms and stop the disease process. Commonly used drugs are;

  • 5-ASA (Amino salicylic acid)
  • Glucocorticoids
  • Antibiotics “ Metronidazole and Ciprofloxacin
  • Azathioprine and 6-mercaptopurine
  • Methotrexate
  • Cyclosporine
  • Anti TNF agents “ Infliximab and Adalimumab
  • Monoclonal antibody – Golimumab

For detailed description of the mechanisms and side effects of the drugs please visit;






It seems that in order to lose weight it is not important only what we eat but also when we eat. Now a group of researchers at Tel Aviv University found that people who eat their largest meal at breakfast are more likely to lose weight than people who eat a rich dinner. The study is published in the journal Obesity and points out that a proper timing of meals is extremely important in the management of obesity.

All this is because the metabolism is influenced by circadian rhythms, that is by the biological processes our body goes through during the 24 hours. Prof. Daniela Jakubowicz of TAU’s Sackler Faculty of Medicine and the Diabetes Unit at Wolfson Medical Center, explained that the time when we eat has a great impact on how our body processes food. It looks like that having a big breakfast has consequences not only on body weight but on health as it was found that these individuals have significantly lower levels of insulin, glucose, triglyceride, which means that the risk of cardiovascular disease is lower.


The researchers came to these conclusions after conducting a study on 93 obese women who were randomly divided into two groups. Both groups received a diet of 1,400 calories per day ( moderate-carbohydrate, moderate-fat diet): one group consumed 700 calories for breakfast, 500 for lunch and 200 for dinner, while  the second group had a 700 calorie dinner and a breakfast of 200 calories. The group with the big breakfast had lost 17.8 pounds and three inches off each their waist line; besides this, researchers discovered that they had much lower levels of ghrelin (hunger-regulating hormone).  Compared to women with the big breakfast, the big dinner group lost only 7.3 pounds. Researchers also found that the participants with the big breakfast did not have high spikes in their blood glucose level, as it happens normally after a meal.

These results highlith to the fact that people should have a timing of meals and a balanced diet. Eating the right food at late hours not only slow down the weight loss process, it can be harmful also. It seems that the participants with the big dinner had an increase in triglycerides levels, despite weight loss. Therefore, Prof. Jakubowicz believes that eating at late hours in front of the TV and computer are the promoters of epidemic obesity. This unhealthy habit not only lead to weight gain but also increases the risk of cardiovascular disease.



Bowel disease symptoms

Autoimmunity is the main culprit behind the chronic inflammation of the digestive tract leading to a medical condition termed as inflammatory bowel disease. The two major types of IBD are ulcerative colitis and Crohn’s disease. Although classified as a single entity, the two forms of disease vary in many aspects.

Based on the etiology and origin, inflammatory bowel disease is classified as;

  • Familial “ it is a familial disease in 5-10% of the individuals. In such cases the disease has early onset usually presenting in the first decade of life. In Crohn’s disease, there is concordance of clinical findings and anatomical sites.
  • Sporadic “ remaining cases of inflammatory bowel disease has no previous family history of the disease. The lifetime risk of first degree relative of an individual suffering from inflammatory bowel disease is almost 10%.

For detailed etiopathogensis of ulcerative colitis and Crohn’s disease please visit;



Although the inflammatory bowel disease, whether Crohn’s disease or ulcerative colitis, involves the gastrointestinal tract primarily, however extra intestinal systems may also be affected due to the ongoing disease process. Extra intestinal manifestations are present in almost 1/3rd of the individuals suffering from inflammatory bowel disease. Common manifestations are;

  • Dermatologic
    • Erythema nodosum “ it occurs in almost 10 % of ulcerative colitis and 15 % of Crohn’s disease patients. The lesions of erythema nodosum are present on the shins, calves, ankles, thighs and arms. It is characterized by red, hot and tender nodules that measure almost 1-5 cm in diameter. Skin lesions usually develop after the onset of bowel symptoms.
    • Pyoderma gangrenosum “ it is less common in Crohn’s colitis and in almost 1-2 % of patients suffering from ulcerative colitis. It commonly presents as pustules on the dorsal aspects of the legs and feet. Other sites involved are chest, stoma, face and arms. Pustules may be single or multiple and they usually ulcerate complicating the disease.
    • Other less common dermatologic manifestations are pyoderma vegetans, pyostomatitis vegetans, Sweet’s dyndrome (cutaneous granuloma formation), psoriasis ( 5-10%), perianal skin tags, aphthous stomatitis and “cobblestone” lesions of the buccal mucosa.
  • Rheumatologic
    • Peripheral arthritis “ it affects almost 15 to 20 % of patients suffering from inflammatory bowel disease. It commonly occurs in the patients of Crohn’s disease worsening with the exacerbations of bowel activity. It involves multiple large joints of the upper and lower extremities, is asymmetric and migratory.
    • Ankylosing spondylitis “ it occurs in almost 10 % of IBD patients and is more common in Crohn’s disease as compared to ulcerative colitis. It commonly affects the pelvis and spine and presents are morning stiffness, pain in buttocks and low backache. Infliximab is effective in relieving the stiffness and alleviates the symptoms associated with it.
    • Sacroiliitis “ it occurs equally in ulcerative colitis and Crohn’s colitis, and is symmetric.
    • Other rheumatic disorders include relapsing polychondritis, hypertrophic osteoarthropathy and pelvic/femoral osteomyelitis.
  • Ocular
    • Incidence is 1-10%.
    • Common ocular manifestations are conjunctivitis, anterior uveitis and episcleritis.
    • Anterior uveitis is associated with both Crohn’s colitis and ulcerative colitis. Common symptoms are blurring of vision, ocular pain, photohobia and headache.
    • Episcleritis occurs in 3-4% of IBD patients with ocular burning being the most common symptom. It occurs frequently in the patients of Crohn’s disease.
  • Hepatobiliary
    • Hepatic steatosis “ patients usually present with enlarged liver.
    • Cholelithiasis “ it occurs in almost 10-30% of the patients having Crohn’s disease.
    • Primary sclerosing cholangitis
  • Urologic
    • Nephrolithiasis
    • Ureteral obstruction
    • Ileal bladder fistulas
  • Metabolic bone disorders
    • Low bone mass
    • Increased risk of spine, wrist and rib fractures
    • Osteonecrosis
  • Thromboembolic disorders
    • Increased risk of venous and arterial thrombosis
    • Vasculitides involving small, medium and large vessels

Bowel disease symptomsInflammatory bowel disease is strongly associated with the development of carcinoma due to chronic underlying inflammation of the digestive tract. Longstanding underlying ulcerative colitis and Crohn’s disease increase the risk of epithelial dysplasia and carcinoma of colon. Here are few risk factors associated with the developmental of carcinoma in cases of inflammatory bowel disease;

  • Extensive and long duration IBD
  • Positive family history of the disease
  • Development of strictures
  • Associated primary sclerosing cholangitis (PSC)

Inflammatory bowel disease can affect any age group. When children are affected with IBS, the management becomes complex. In children IBD usually presents with fatigue and irritability of a normal child. The treatment must be started as soon as possible. The most important step is the dietary management that is difficult to be done strictly in the children. Balanced diet with sufficient calories in it must be provided to the children because they may have malnutrition due to diarrhea of IBD. Moreover, children must be encouraged to take healthy small meals and avoid fatty junk food that can worsen the IBD symptoms.

Bowel disease

Bowel disease

Although home remedies, alternative medicine, prescription drugs and nutritional therapies have shown promising results in the management of inflammatory bowel disease,

Table of Biological Therapies

Table of Biological Therapies

however in some cases surgery become inevitable. Here are the common indications for which surgery becomes mandatory in order to save the digestive tract and alleviate the symptoms of inflammatory bowel disease;

  • Ulcerative colitis
    • Intractable disease
    • Toxic megacolon
    • Colonic perforation
    • Massive colonic hemorrhage
    • Extracolonic disease
  • Crohn’s disease
    • Stricture and obstruction
    • Abscess
    • Perianal disease unresponsive to medical treatment
    • Cancer prophylaxis



Causes of Colon Cancer

General Considerations: Colon cancer is the second most common cancer and cancer killer in the adults. It develops in approximately 6% of Americans and 40% of those die of the disease. Colon cancer when seen through an instrument called colonoscopy appears like bulky out growth protruding into the colon lumen or it may be like a constricting ring narrowing the colon lumen.

Followings are considered to be the possible causes of colon cancer:

  • Polyp- an outgrowth in colon lumen that can transform into the colon cancer
  • Loss of function of tumor suppressor gene- a tumor suppressor gene is a part on DNA suppressing the growth of tumor cells
  • Activation of oncogenes- oncogenes are genes involved in proliferation of tumor cells
  • Inherited syndromes

A polyp is an outgrowth in the bowel wall protruding into the bowel lumen. It is formed in the bowel wall because of excessive proliferation of normal cells. It is one of the major causes of colon cancer. The current thought is that the majority of the colon cancers arise from the malignant change of a polyp i.e. when cells in the polyp grow excessively and immaturely, they can give rise to colon cancer. Genes are parts of DNA that control different body functions like growth and differentiation of cells. Tumor suppressor genes normally suppress the growth and division of our body cells. When they lose function properly, cells grow in an uncontrolled way thus leading to cancer. There are many such tumor suppressor genes whose dysfuntining is an important cause of colon cancer. Oncogenes are genes which when activated cause the growth of cancer cells. Activation of many such genes is one of the causes of colon cancer. Up to 5% of the colon cancers are caused by inherited germ line mutations resulting in polyposis syndromes- syndromes having many polyps in colon1.

Risk Factors

It is thought that there are many risk factors which coexist with underlying cause of colon cancer. Early detection of these factors has an impact on screening strategies. However, 75% of all cases of colon cancer are seen in those people with no known predisposing factors. These risk factors include the followings:

  • Age
  • Family history of cancer
  • Inflammatory bowel disease
  • Dietary factors
  • Others

The incidence of colon cancer increases swiftly after the age of 45 years, and 90% of the cases occur after the age of 50 years. A family history of colon cancer is seen in 20% of the patients with colon cancer. Hereditary factors are the cause of colon cancer in 20-30% of the cases. Inflammatory bowel disease is another important cause of colon cancer, the risk of colon cancer tends to increase after 7-10 years of disease onset. Chronic treatment with 5-aminosayliclic acid and folic acid in patients with inflammatory bowel disease is associated with low risk for development of colon cancer. The diet rich in fats or red meat increases the risk of colon cancer while diet containing fibers, fruits, grains and vegetables is associated with decrease risk of colon cancer. The incidence of colon cancer is higher in blacks than in whites. Diabetes, metabolic syndrome, obesity and cigarette smoking are associated with modest increase in cancer risk. Metabolic syndrome refers to group of risks that cause heart diseases and diabetes.

Clinical Findings

The clinical symptoms and signs of colon cancer depend upon the location of the cancer. Generally followings are the clinical features of a colon cancer2:

  • Anemia
  • Fatigue
  • Generalized weakness
  • Blood in stool
  • Alternating bowel habits
  • Constipation
  • Feeling of incomplete evacuation of bowel after defecation
  • Colicky abdominal pain
  • Loss of appetite
  • Weight loss

Left sided colon cancer tends to obstruct the bowel and patient presents with alternating bowel habits, constipation and colicky abdominal pain- the pain that comes and goes. Right sided colon cancer tends to bleed and it presents with features of anemia, fatigue, weakness and a swelling in right iliac fossa1,2,3.


Following investigation are carried out for diagnosis and selection of treatment option of colon cancer2,3 :

  • Stool examination for presence of occult blood
  • Colonoscopy and biopsy of the cancer is the gold standard test for diagnosis of colon cancer
  • Complete blood count to check for the anemia
  • Liver function tests
  • Ultrasonography of abdomen and pelvis to confirm the spread of cancer
  • CT scan of chest, abdomen and pelvis to look for spread of colon cancer
  • Carcinoembryonic antigen (CEA) levels- a tumour marker
    Causes of Colon Cancer

    Colon Cncer and Polyp


    Fig: Locations of Colon Cancer5


    Causes of Colon Cancer

    Locaton of Colon Cancer


    Fig: Clonoscopic view of colon cancer6



Prevention of Colon cancer

Followings are some handy points that can prevent occurrence of colon cancer2:

  • Use of aspirin prevent the colon cancer development
  • Oral folic acid and oral calcium supplements reduce the risk of colon cancer
  • Antioxidant vitamins have some role in prevention of colon cancer
  • Use of estrogen replacement therapy in females reduces the risk of colon cancer
  • Avoid fatty foods and red meat
  • Use fibers, grains and vegetables more
  • Regular screening via colonoscopy for early detection of causes of colon cancer

Treatment Options

Following are the available options for treatment of colon cancer:

  • Surgery
  • Chemotherapy
  • Radiotherapy


Surgery is the treatment of choice for early stages of colon cancer. During surgery the involved part of the colon is resected. For advanced stages of colon cancer when it spreads to other sites, a palliative surgery can be done to relieve the pain and other symptoms of colon cancer. If the cancer spreads to liver, surgical resection of some part of it can be done2.


It means treatment of colon cancer by giving some chemical drugs that can kill the cancer cells. Usually, chemotherapy is used after surgery to kill the remaining cancer cells. The drugs which are used in colon cancer treatment include folinic acid, 5-Flourouracil and irinotecan2.


As colon cancer is radio-resistant radiation has no significant role in treatment of colon cancer. It is used externally or internally to relieve the pain of colon cancer as it reduces the size of cancer cells2,4.


  1. Papadakis MA, Macphee SJ, editors. Current Medical Diagnosis and Treatment.52nd ed. New York: Mc Graw Hill Medical; 2013.
  2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, ed. New Delhi: Mc Graw Hill Medical; 2012.
  3. Bhat S. SRB’s manual of surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2009.
  4. Colon cancer pain [Internet]. 2010 [updated 2010 May 16; cited 2013 July 17]. Available from: http://colon-cancer.emedtv.com/colon-cancer/colon-cancer-pain.html.
  5. Colon cancer (colorectal cancer [Inyernet]. 1996 [updated 2012 Apr 10; cited 2013 Jul 20]. Avaialble from: http://www.medicinenet.com/colon_cancer/article.htm.
  6. Colon polyps and cancer [Internet]. 2008 [cited 2013 Apr 20]. Available from: http://gjgastro.com/Education/Colon_Polyps.html.


Management of Colon Cancer

Management of colon cancer includes investigations or tests (to have some tests aid the diagnosis) and treatment options which may be surgical or radiotherapy or some home remedies.


The following investigations or tests may be performed to diagnose colon cancer1,2:

  • Barium enema- a special x-ray of the large intestine
  • Colonoscopy- a procedure to see inside the colon
  • Biopsy- a test to see cancer cells in the specimen taken
  • CT Colonoscopy- a special test which uses x-rays and computers to produce high quality images of colon
  • Ultrasonography- sees the deep structures of the body using ultrasonic waves
  • Carcinoembryonic antigen (CEA)- a cancer marker for colon cancer
  • FNAC (Fine needle aspiration cytology)- a test to see cancer cells in the specimen taken from the patient
  • Complete blood count
  • Haematocrit
  • ESR
  • Liver function tests

Management of colon cancer sometimes includes advanced techniques like laproscopic surgery. Laproscopic procedure is given below3:

Laproscopic Procedure

Laproscopic Procedure

Colonoscopy examines the whole large bowel; the demonstrated image is shown below4:

Colon Cancer

Colon Cancer

Barium enema shows irregular filling defect and apple core lesion in left sided colon cancer. Colonoscopy and biopsy confirms the diagnosis of colon cancer. CT Colonoscopy is also useful to visualize the entire colon. Ultrasonography should be done to see the secondaries in liver, peritoneum, and lymph node status and rectovesical pouch.

Carcinoembryonic antigen (CEA) is a cell surface glycoprotein that is normally produced by colonic epithelium. Its normal value is less than 2.5ng/ml. Level of CEA above 5ng/ml is significant for the diagnosis of colorectal cancer. Even though it is widely used tumor marker but it has got low sensitivity.

Left supraclavicular lymph node if palpable, its FNAC may clinch the histological diagnosis of colon cancer. Other baseline investigation like complete blood count, haematocrit, ESR, hemoglobin level and liver function tests must be carried out. CT scan abdomen and pelvis can be done to see local spread, invasion, size and extent of tumor, nodal status and liver secondaries2.

Treatment options


Treatment of colon cancer is mainly surgical. The following surgical procedures can be done:

  • Right radical hemicolectomy- an operation where right half of the large bowel is removed.
  • Ileo-transverse anastomosis- a surgical procedure where a part of small bowel (the ileum) is joined with the portion of large bowel (the transverse colon).
  • Left radical hemicolectomy- an operation where left half of the large bowel is removed
  • Colostomy- a procedure where one end of colon is brought out through the abdominal wall.
  • Hemihepatectomy- a surgical procedure where half or a lobe of liver is removed
  • Laparoscopic evaluation and resection

In right sided early growth, right radical hemicolectomy with ileo-transverse anastomosis is done. In inoperable right sided growth ileo-transverse anastomosis is done as bypass procedure. In left sided early growth left radical hemicolectomy is done.

Left sided stenosing type of growth can present with acute intestinal obstruction, in which case initially colostomy is done. Later, after 3-6 weeks, following proper preparation required normal procedure is done, followed by colostomy closure after 8 weeks (3-stage operation).

In solitary liver secondary, segmental hepatic resection is useful. In case of multiple secondaries confined to one lobe of liver, hemihepatectomy can be done. Laparoscopic evaluation and resection is becoming popular now days.

Adjuvant therapy:

It includes chemotherapy and radiotherapy.


Indications for chemotherapy include lymph node involvement, involvement of adjacent organs, venous spread, signet cell type carcinoma, poorly differentiated tumor and changes in CEA level. Postoperative chemotherapy is used commonly. 5-Fluorouracil with folinic acid is the most commonly used regime for six months as monthly cycles. Other drugs being used are irinotecan, oxaliplatin, capecitabine and cetuximab.


Usually there is no role of radiotherapy as tumor is radio-resistant. It is often used in locally advanced tumor, infiltrating the psoas major muscle or lateral abdominal wall. It is also used in inoperable recurrent tumor.

Colon Cancer Pain and its Management

Colon cancer can cause pain by obstructing the intestinal lumen, by pressing against the nerves or bones and by spreading to the nearby or distant organs. Option for pain management includes:

  • Medicines
  • Alternative treatments
  • Surgery
  • Radiation
  • Nerve block

The medicines that can relieve pain may be oral or intravenous opoids or some type of NSAIDS5.

Alternative management of colon cancer includes the treatment with massage, acupuncture and acupressure. Pain can also be relieved by learning relaxation techniques like listening to slow music or breathing slowly and comfortably.

Radiations can relieve the cancer pain by shrinking the tumor; it can be applied externally or internally. Radiation therapy can be used with or without chemotherapy or surgery. Surgery is the main treatment for early colon cancer and it is especially useful to relieve the pain when tumor is obstructing intestine.

Alcohol can be injected around the nerves of colon, involved in causation of cancer pain- a nerve block.

Home remedies for Colon Cancer

Home remedies also play an important role in the management of colon cancer. Establishing a healthy nutrition via dietary modifications is one of the most efficient home remedies for colon cancer. The following home remedies can be taken in account if you are suffering from colon cancer pain:

  • Eat healthy food
  • Add dietary fiber to your food
  • Use grains
  • Eat fruits and vegetables
  • Use olive oil and omega-3 oils
  • Decrease the use of red meat
  • Add turmeric spice to your food

The patient should eat well to get the much required nutrients and calories to establish or improve physical strength and increase the capability of the immune system. The diet of patient must include dietary fiber, grains and foods like fruits and vegetables must be an important part of daily intake.

Also, the patient must use foods with good fats like olive oil and omega-3 oils. It is also necessary to decrease the intake of red meat.

Turmeric is a curry spice and it is used in Indian traditional medicine. Its active ingredient is curcumin, which is protective against colon cancer. One teaspoon of fresh turmeric powder mixed in boiled water can be used as a home remedy to cure colon cancer. It can be used three times a day for six months6.


  1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison’s principles of internal medicine. 18th ed. New Delhi: Mc Graw Hill Medical; 2012.
  2. Bhat S. SRB’s manual of surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2209.
  3. Ideas for surgery [Internet]. 2008 [cited 2013 July 21]. Available from: http://www.ideasforsurgery.com/.
  4. Colon caner [Internet]. 2012 [updated 2012 Nov 17; cited 2013 July 21]. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001308/.
  5. Colon cancer pain [Internet]. 2010 [updated 2010 May 16; cited 2013 July 17]. Available from: http://colon-cancer.emedtv.com/colon-cancer/colon-cancer-pain.html.
  6. Colon cancer [Internet]. 2006 [updated 2006; cited 2013 July 17]. Available from: http://www.homeremedycentral.com/en/natural-cures/home-remedy/colon-cancer.html.


Colon cancer is the second most common cancer in adults and second major cause of cancer deaths in United States. Its incidence has much decreased in the last two decades due to early detection via screening and availability of good treatment options for early stage tumor. Age more than 50 years, presence of polyp (an outgrowth in the colon lumen from its wall due to excessive proliferation of cells), loss of function of certain genes, more intake of fats and red meat and tobacco smoking are all possible risk factors for the development of colon cancer1.

Colon Cancer Staging

Colon cancer like almost all other cancers has ability to spread, and colon cancer staging measures this ability. Simply, the staging is a process by which we determine the extent of spread of cancer from its original primary location1-3. Colon cancer staging tells us that whether the cancer is present within the colon wall or it has spread to the other organs of the body. Staging of colon cancer is important because it helps us to select a proper treatment option for the colon cancer.

Spread of colon cancer3: Almost every cancer has property to spread from its primary site; this property is termed as metastasis. The metastasis is one of the important parameter in colon cancer staging. Colon cancer can spread by three ways:

  • Direct spread to entire colon wall, urinary bladder and ureter, ovaries and uterus.
  • Lymphatic spread (spread through lymph vessels) to different group of lymph nodes.
  • Blood spread to liver, bone, lung and skin.


Investigations for colon cancer staging: Following investigations are carried out for staging of colon cancer1-3:

  • CT Chest to determine the spread of cancer to lungs
  • CT Abdomen and pelvis to determine the spread of cancer to liver, lymph nodes, ovary, uterus, ureter, urinary bladder and rectum.
  • Ultrasonography of abdomen to determine liver involvement
  • Pelvic MRI and endorectal Ultrasonography identifies the depth of penetration of cancer through colorectal wall and adjacent lymph nodes
  • Dissection of involved lymph nodes
  • Liver function tests to see liver involvement
  • Complete blood count to see bone involvement
  • Bone scan to see bone involvement
  • Colonoscopy and biopsy of the involved area.

Types of Staging of Colon Cancer: Following are some types of staging of colon cancer3:

  • Duke’s staging
  • Modified Duke ‘staging
  • Astler-Coller’ staging
  • TNM-system

Duke’s staging3: According to this staging extent of colon cancer can be described in three stages:

  • Cancer confined to bowel wall but not involving whole thickness of wall and lymph nodes.
  • Cancer involving entire thickness of bowel wall but not involving the lymph nodes.
  • Lymph nodes are also involved along with entire colon wall.

Modified Duke’s staging3: according to this staging extent of colon cancer can be described into four stages:

  1. Cancer limited to colorectal bowel wall.
  2. Cancer extending up to tissues around the colorectal wall but not involving lymph node.
  3. Lymph node involvement.
  4. Cancer with distant spread to liver, lungs, bone and brain.

Astler-Coller’s staging3: It includes following stages of colon cancer:
A. Cancer involving inner third of bowel wall
B1. Cancer involving inner two third of bowel wall
B2. Cancer involving entire thickness of bowel wall and spread into peritoneum

C1. Cancer involving inner two third of bowel wall and involvement of lymph nodes
C2. Cancer involving entire thickness of bowel wall and spread into peritoneum and involvement of lymph nodes

D.Distant spread of cancer.

TNM- staging3: The TNM-staging is more commonly used classification than above described types to stage colorectal cancer. It uses three parameters to stage the colon cancer i.e.

  • T- Which means invasion of colon cancer
  • N- Which means involvement of lymph node
  • M- Which means metastasis or spread to distant organs

According to this system colon cancer can be staged as follows:

Tsitu-Carcinoma in situ that means cancer without invasion

T1- Invasion into submucosa (inner third of bowel wall)

T2- Invasion into muscularis (inner two third of bowel wall)

T3- Invasion into fat surrounding the bowel wall

T4- Invasion into the adjacent organs

N0- No lymph node involvement

N1- Up to three lymph nodes are involved

N2- Four or more than four lymph nodes are involved

M0- No distant spread is present

M1- Distant spread is present

An illustration of staging of colon cancer is given below4:

Colon Cancer Staging and Prognosis

The stage of colon cancer at presentation is the most important determinant of long term survival. The patients with colon cancer involving only colonic submucosa without lymph node involvement or distant spread have survival rate of more than 90%. The patients with colon cancer involving less than 4 lymph nodes have survival rate of 67%. The patients with colon cancer involving more than 4 lymph nodes have survival rate of 33%. The patients with colon cancer involving distant organs have survival rate of 5-7%1. Prognosis also depends upon the following facts3:

  • Site- Left sided cancer has better prognosis as they present early
  • Type- Colloid cancer (histological type of colon cancer) has got poorer prognosis
  • Size- Large sized tumor has got poorer prognosis
  • Associated diseases like AIDS make the prognosis poor.
  • Age- Age more than 50 years makes the prognosis poor.

Another illustration of staging for colon cancer is given below5:


  1. Papadakis MA, Macphee SJ, editors. Current Medical Diagnosis and Treatment.52nd ed. New York: Mc Graw Hill Medical; 2013.
  2. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, ed. New Delhi: Mc Graw Hill Medical; 2012.
  3. Bhat S. SRB’s manual of surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2009.
  4. Colonoscopy and colyte can be fun if you do it right [Internet]. 2011 [cited 2013 July 17]. Available from: http://www.probaway.com/helps/.
  5. Staging colon cancer [Internet]. 2012 [cited 2013 July 21]. Available from: http://www.thecolorectalinstitute.com/staging-colon-cancer/.



Colon Cancer and Colon Pain


Colon pain can sometimes be a presentation of Colon Cancer or cancer of the large intestine. Colon Cancer is the second most common cause of cancer death in United States: 142,570 new cases reported in 2010, and 51,370 deaths occurred due to cancer of large intestine.

Good screening practices, early detection and improved treatment options for colon cancer have decreased the mortality by 25% in United States in the last decade1. One of the most common presentations of colon cancer is colon pain that refers to vague pain in the tummy.

Adenocarcinoma is the most common diagnosis on histological examination. Very rarely, it may be of two types:

Adenosquamous- a type of cancer that contains gland like as well as thin flat cells

Squamous cell carcinoma- a type of cancer having only thin flat cells

Sigmoid colon is the most common site of malignancy (21%) after rectum (38%), having incidence of 12%.

Risk factors

The risk factors for the development of colon cancer include:

  • Diet
  • Hereditary syndromes- groups of conditions that are inherited from the parents
  • Inflammatory bowel disease
  • Streptococcus bovis bacteremia
  • Ureterosigmoidostomy “ a surgical procedure where ureter is implanted in the sigmoid portion of the intestinal tract.

Regarding etiology, environmental factors are mainly associated with large bowel cancer. Colon cancer is seen more often in upper socioeconomic population who live in urban areas.

The mortality from colon cancer is directly related with per capita use of calories, meat protein, dietary fat and oil and elevations in serum cholesterol levels.

In almost 25% of the patients with colon cancer have a family history of the disease, suggesting a hereditary predisposition.

The two important hereditary conditions associated with colon cancer include:

  • Polyposis coli- a condition where alteration in the genes occurs
  • Lynch syndrome- a hereditary condition which causes colon and rectal cancers

The patients suffering from ulcerative colitis have increased incidence of development of colon cancer especially after duration of 10 years. It is observed that cigarette smoking of more than 35 years is associated with colorectal adenomas. Dietary vitamins A, E, C and zinc reduce the risk of colon cancer1,2.

Clinical presentation

The patient with colon cancer may present with:

  • Colon pain “ a vague pain in the tummy
  • Change in bowel habits
  • Blood in stools
  • Persistent abdominal discomfort
  • Loss of weight
  • Fatigue
  • Anaemia
  • Diarrhea
  • Constipation
  • Incomplete evacuation

The image below shows colon cancer on colonoscopy3:

Colon Cncer

Colon Cncer


Patient with colon cancer can have newly developed multiple primary carcinomas in different parts of colon at the same time. It can also present with growth in different parts of the colon at different periods1.

Grossly a colon cancer may be of different types like:

  • Annular- a ring like growth
  • Ulcerative- cancer growth with ulcers
  • Tubular- having the form or shape of a tube
  • Proliferative- grows rapidly to produce cells

The annular type is most commonly seen on left side, here the growth spreads round the internal wall and so it often presents with features of intestinal obstruction. Ulcerative and proliferative types are seen commonly on right side.

The symptoms of colon cancer vary with location of tumor. The stools which pass to right-sided colon from ileocecal valve (valve found between the small bowel, the ileum and the portion of large bowel, the caecum) are relatively liquid so the cancer arising in ascending colon may become large without resulting in any obstructive symptoms or alterations in bowel habits. Tumor of right sided colon often tends to ulcerate, leading to chronic, slow blood loss without a change in the appearance of stool. So, patients with cancer of ascending colon often present with symptoms such as fatigue, palpitation, angina and are found to have hypochromic microcytic anemia (blood with less and small red blood cells with increased pallor in the center).

On left side, in ascending colon cancer, a mass may be palpable in right lower abdominal region (right iliac fossa), which does not move with respiration, mobile, painless, hard and well-localized with abnormal hollow sounds (impaired resonant note). Patients with left-sided colon cancer may experience colon pain.

Carcinoma of caecum occasionally presents like acute appendicitis (inflammation of the appendix which lies behind the start of the large bowel) or intussusceptions with intestinal obstruction. In intussusceptions, the inversion of one portion of the intestine within another occurs.

As stool passes in transverse or descending colon, it becomes more formed so the growth arising there tends to obstruct the passage of stool resulting in abdominal cramping, occasional obstruction, and even perforation. In simple words the left sided growth presents with colicky pain abdomen (colon pain), altered bowel habits, palpable lump and distension of abdomen due to sub-acute or chronic obstruction. Tenesmus (feeling the need of pass stools while the colon is empty), with passage of blood and mucus, with alternate diarrhea and constipation, is common.

Bladder symptoms may warn colovesical fistula (connection between bladder and the part of colon). The illustration shows colovesical fistula3:

Colovesical Fistula

Colovesical Fistula


Closed loop obstruction causing colon pain can occur in transverse colon growth with competent ileocecal valve. Enlarged liver with multiple umblicated hard secondaries, asicites, rectovesical (behind the bladder) secondaries, palpable left supraclavicular lymph nodes are the other presentations of colon cancer1,2.

Studies have revealed that colon pain is prevalent among well-functioning ambulatory patients and in half of them it affects their functions and daily life4. However, more frequent colon pain can cause more compromise to the patients with colon cancer.


  1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison’s principles of internal medicine. 18th ed. New Delhi: Mc Graw Hill Medical; 2012.
  2. Bhat S. SRB’s manual of surgery. 3rd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2209.
  3. Avritscher R, Madoff DC, Ramirez RT, Wallace MJ, Ahrar K, Morello JrFA, et al. Fistulas of the Lower Urinary Tract: Percutaneous approaches for the management of a difficult clinical entity. Radiograph
    2004; 24: S217-S236.
  4. Portenoy RK, Miransky J, Thaler HT, Horning J, Bianchi C, Cibas-Kong I, et al. Pain in ambulatory patients with lung or colon cancer. Prevalence, characteristics, and effect. Cancer 1992;70(6):1616-24.



New Research Provides Hope for Down Syndrome Patients

We know how hard it is to be a parent to a child with Down’s syndrome. Being a parent to this special child can be a huge physical and emotional challenge for you and for the other members of your family. But it helps to hear that you are not alone in your daily challenges.

There is no treatment or method of prevention for Down’s syndrome, though some health problems that come with it can be treated. However, a new study has found out one molecular mechanism behind this disease, creating a possibility for treatment discoveries.

In this study published in Nature Medicine, scientists from California have found out that there is a connection between Down’s syndrome and a protein called SNX27 (sorting nexin 27). This protein regulates certain receptors in the surface of nerve cells. These receptors are known as glutamate receptors and they facilitate communication between cells through a neuromediator called glutamate. Glutamate transmits nerve signals from one nerve cell to another.

Glutamate receptors respond to the presence of glutamate molecules in a specific manner. If glutamate receptors are lesser in amount than normal, there is lesser communication among nerve cells and this result to impairment of cognitive function. This is what happens in Down’s syndrome. In people with Down’s syndrome, protein SNX27 levels are lower compared to that of normal people. The investigators of this study have also discovered that chromosome 21 carries a gene which has a certain substance that decreases the production of SNX27 in neurons.

In this particular study, mice with Down’s syndrome were studied. The experts were able to demonstrate that if the production of the inhibitory compound affecting SNX27 levels is blocked, normal brain and nerve function may return. The investigators then blocked the production of SNX27 in neurons through gene therapy. With these findings, there is a possibility that cognitive impairment in humans with Down’s syndrome can be effectively treated with gene therapy.

Indeed this is good news for parents who have children with Down’s syndrome. Hopefully, gene therapy can be done in actual human patients in the near future so that patients with Down’s syndrome can have improvement in cognitive function and can effectively function in society.

Down Syndrome

Down Syndrome

Image from http://www.cdc.gov/ncbddd

According to the Centers for Disease Control (CDC), one of every 800 babies born in the United States every year has Down’s syndrome. These babies are born with an extra copy of chromosome 21, a fact which makes them special.

Down’s syndrome, also called Trisomy 21, can lead to various problems, both mentally and physically. It can cause delays in child development and physical symptoms such as poor muscle tone, a flattened nose, a flat face, a short neck, excess skin at the back of the neck, small head and small ears and mouth. Other physical attributes of these patients include an upward slanting of the eyes, white spots on the colored part of the eyes, short hands with short fingers, a single deep crease on the palm of the hand and a deep groove located in between the first and second toes. These physical characteristics can cause isolation and humiliation for the patient so that his or her emotional health is affected.

In terms of intellectual development, children with Down’s syndrome often have mild to moderate cognitive problems. These children may have a short attention span, poor judgement, slow learning, impulsive behaviour, and delayed language or speech development. Other problems may include heart defects, vision problems, hearing loss, infections, hypothyroidism, blood disorders, problems with the spine, poor muscle strength and tone, disturbed sleep, gum and teeth problems, epilepsy, digestive problems and various mental and emotional problems.


  1. US Department of Health and Human Services National Institutes of Health. Down Syndrome: Condition Information (2012). Retrieved June 20, 2013 from http://www.nichd.nih.gov/health/topics/down/conditioninfo/Pages/symptoms.aspx
  2. Jones MW. Sorting receptors at Down’s syndrome synapses. Nat Med. 2013 Apr;19(4):404-6.


Having knowledge of IBS foods to avoid become critical when it comes to cure this gut complication. Irritable Bowel Syndrome (IBS), mucous colitis, spastic colon are different terms used to refer a single disorder of gastrointestinal tract characterized by symptoms like constipation alternating with diarrhea, bloating, pain in the lower abdomen and passing of mucous in the stool. Among the several causes of irritable bowel syndrome, dietary triggers are the most important. If you are suffering from IBS then you should consider revising your eating routine. Foods to avoid depend on the symptoms with which an individual presents. You should change your dietary habits in accordance with your major symptoms.

  • Foods to avoid when you have IBS with bloating:

    Bloating, in the case of irritable bowel syndrome, is most frequently caused by eating food rich in starch which is not easily digested in the gut. The fermentation of this food causes bloating (carbohydrate intolerance). If this is the case then you should consider cutting short following things in your diet:

    • Avoid eating reheated or poorly cooked starch rich foods like potatoes and corns.
    • Dried pasta can aggravate the symptoms of bloating in irritable bowel syndrome. So, try eating fresh pasta instead.
    • Processed food containing pasta and potato, like macaroni cheese, lasagna etc, should be avoided.
    • Bread and majority of bakery products are also rich in starch. So, partly cooked or reheated bakery products should be skipped in spastic colon. Such products include cakes, biscuits, pizzas and garlic breads.
    • The use of fruits like green bananas should also be minimized.
    • Pulses, corns (especially sweet corn) and whole grains make another important IBS trigger group.
    • Avoid eating fried rice, baked potatoes or potato waffles. Instead, choose boiled rice and baked potatoes.
    • “Ready to eat” starch containing food, including potatoes, sweet corn and pasta, should be avoided. Eat freshly cooked food instead.
    • Minimize the use of gas producing vegetables like cabbage and broccoli
  • Foods to avoid when you have IBS with diarrhea:

    Sometimes the major symptom of irritable bowel syndrome is diarrhea. What you need to do is to replace the lost fluids and eliminate the basic trigger of diarrhea. Following dietary restrictions should be kept in mind:

    • Replace the lost fluids with plain water, not with caffeinated drinks like colas, coffee, squashes, energy drinks and tea.
    • Try to limit the use of caffeinated drinks and much as possible. But, if you still choose to drink such drinks then don’t drink more than 2-3 cups (of tea or coffee) a day.
    • Avoid fizzy drinks.
    • It’s best not to drink alcohol when you are suffering from IBS with diarrhea.
    • Human gut lacks the enzymes required to digest fibers present in seeds, wholegrain breads, cereals and bran. These insoluble fibers remain in the gut and drain the water of gut leading to the further complication of diarrhea symptoms.
    • You shouldn’t eat the pits and skins from the fruits and vegetables.
    • Restrict the intake of reheated or undercooked starchy foods (as described above).
    • Avoid eating sweets (gums and candies) containing sorbitol.
    • Avoid eating food containing high content of fat like hamburgers, chips, sausages and cakes.

    • Foods to avoid when you have IBS with constipation:

      Constipation is the major presentation of mucous colitis in majority of cases. Following precautions should be kept in mind regarding dietary habits:

      • Don’t increase the intake of insoluble fiber too rapidly. Insoluble fibers do help in abating the symptoms of constipation but these fibers complicated the other presentations of spastic colon i.e. bloating, abdominal pain, flatulence and diarrhea. Increase the quantity of these fibers slowly.
      • Due to their dehydrating effect, drinks like alcohol, coffee and caffeinated beverages should be avoided in mucous colitis with constipation.
      • Eating too refined food can worsen the constipation. The use of food items like cookies, white rice and white bread should be discouraged.
      • Constipation is the major side effect of eating the most popular “high protein, low carbohydrate diet”. You do need proteins but cutting short your carbohydrate sources (fruits and vegetables) is going to do more harm than good.

    • Food to avoid when you have IBS with abdominal pain:

      IBS foods to avoid when you’re suffering from abdominal pain include:

      • Eating fried, greasy and fatty food stuff can complicate the abdominal pain associated with spastic colon.
      • Eating heavy meals can stimulate intense stomach and intestine contractions leading to severe pain.
      • Avoid eating gas producing food products (as described above).


To conclude, having knowledge of different IBS foods to avoid, you can devise a perfect diet plan which can help you fight against irritable bowel syndrome.







Photo crédits:



Don’t like wrinkles? Don't smoke!

Smoking is always killing. There has been no positive effect of smoking . Being a female, if you are worried about your beauty, then say goodbye to your habit of smoking. Although many of us are well educated and aware of the bad consequences of smoking but still we smoke with the same passion. It’s not that you cannot quit smoking. If you are willing to do it, then you can do it.

Do you know that each year, almost 150,000 females die because of diseases caused by smoking? Almost 27 percent of the females between the age of 25 and 45 are found smoking cigarettes. It is not teens and adult females that are caught up in the habit of smoking. Do you know that more than 1.5 million of teenage girls in the country are smokers too? Mostly, the habit of smoking is adopted during the teenage when you either smoke to get off your mind from something or you think it is fun. But in reality, it is never fun. This habit of yours can take you away from this world.

Smoking and wrinkles

Forget about Cancer, if that’s not what makes you fearful then probably this fact will. What is that fact? WRINKLES! Yes, if you are going to continue smoking than you are going to lose your beauty. Take a look at yourself in the mirror. Are you getting old? Do you see any wrinkles? If there are then it’s due to smoking. Although you might see images on the packets of cigarette that might be stopping you to smoke but still people remain addicted to this habit. We always give ourselves reasons of not doing what we don’t like.

It is proven that smoking is a cause for skin damage 2nd only to sun exposure. Smoking prevents absorption of Vitamins A and C. Those vitamins helps skin protection .When smoking, the smoke generates free radicals known to be harmful for one’s skin. Free radicals free radicals electrons from the skin cells  thus damage them. For each cigarette smoke puff, a trillion free radicals enters the lungs.  Some float in the air while others circulates the body, causing both inflammatory reaction and also reduces the amount of collagen in the skin (collagen in the protein that in responsible for elasticity and smoothness of skin).

A study held at the Michigan University showed that smoking results in wrinkles on the face and upper arm, men and women alike. Those wrinkles then to appear on various body parts, but mainly on the face and upper arm.

On another  research by Professor Brain Williams from the Stirling University says that 8 out of 10 smokers wish to quit. If the patients are targeted with such images that relate to their own concern then it can be highly effective in helping them to quit. Professor Williams along with his colleagues studied the responses of people to the packaging of the cigarette boxes. When the packaging had image related to aging, the female smokers were influenced by it significantly. On the other hand, men were highly affected when images related to impotence and reduced sex drives were used. The study showed that if a particular group of people are targeted as per their issue, then it can significantly help in conveying the message of quitting smoking.

Smoking and pregnancy

Wrinkles are not the only problem caused by smoking among females. It can also be really bad for the health of a woman who is pregnant. If a woman is smoking during pregnancy then it can turn out to be a bad news for her fetus. It has been reported that almost 33 percent of the females continue smoking throughout their pregnancy. That would probably be because of the fact that nicotine addiction is not too easy to get rid of. All the toxins in tobacco can enter into the blood of the mother and the same intoxicated blood is passed to the baby. This can lead to a number of complications for the mother and the survival of the baby can become risky. Sometimes, the mothers have to go through pre-mature delivery. They are at a higher risk of miscarriages and newborn deaths. If a smoking pregnant lady has successfully given birth to a baby, there will definitely be problems in the respiratory system of the child and he might even have ear infections. This indeed would be dangerous for the infant.

this is just the beginning of problems, there are a series of issues that might further appear during the development of the child. Because of smoking, the distribution of hormones is likely to be disturbed. The mother can have complications in breastfeeding. The failure of breastfeeding will make the mother as well as the new born suffer. If the mother continues to smoke after giving birth too, the breast milk will have a mixture of nicotine in it that will be really problematic for the infant.

Tips to quit smoking:

The habit of smoking sure is not easy to quit. So, if you wish to quit, then you will have to take minor steps to begin with.

  • Shift yourself on the electronic cigars for the time being.
  • Convince yourself for quitting the bad habit. You will definitely have withdrawal symptoms but be patient because you can overcome them with time.
  • Start chewing gum to distract yourself. You can try the nicotine chewing gums that have been introduced as the Nicotine Replacement Therapy. Many of the doctors suggest that they can bring down the nicotine addiction and help the person in quitting smoking.
  • You can always take some professional help if nothing is working. There are always smoke rehabilitation centers available that can help the addicts to rehabilitate and live a normal life again.

Even smoking can result in decreased fertility in men. Apart from diseases like lungs cancer, gum problems and a number of other health issues, smoking among men can affect the sexual life too. Males might feel decreased sexual drive and those who are already on the borderline of infertility can become completely infertile due to smoking. Hence, smoking is not useful for men and women in any way.


Forget Cancer: Vanity Will Stop People Smoking: Sunday Times 2 (http://www.sundaytimes.lk/130630/sunday-times-2/forget-cancer-vanity-will-stop-people-smoking-50793.html)

Fear Of Impotence And Wrinkles Drive Smokers To Quit: Medical Specailists (http://medical-specialists.blogspot.co.il/2013/06/fear-of-impotence-and-wrinkles-drive.html)