A gallstone formed within the gallbladder as a result of changes in bile acid (BA) metabolism and gallbladder function are critical factors in the pathogenesis of gallstones. Gallstones can cause blockage the flow of bile through the bile ducts that can lead to inflammatory causes of acute cholecystitis. Gallstones are most common among older adults, women, overweight people, etc.
A. Symptoms
A.1. Common symptoms
1. Upper gastrointestinal bleeding if ruptured
There is a report of a 67-year-old gentleman with no significant medical history of note
presented with sudden onset of epigastric pain, coffee ground vomiting
and passing black tarry stool. The diagnosis of gallstone-induced auto-sphincterotomy was only made, using gastroscope via jejunostomy, when a big gallstone was found in the third part of the duodenum and the papilla was ruptured(1).
2. Right upper quadrant or midline epigastric pain
In a multicenter study was carried out with patients randomized to either
surgery or conservative, expectant treatment to examine optimal
treatment and natural history in well-defined groups of symptomatic
gallbladder stone disease with pain, episodes only (study group 1) or
acute cholecystitis (study group 2). The patients were between 18 and 80
years of age and had right upper quadrant or midline epigastric pain
and ultrasonographic evidence of gallbladder stone, with or without
acute cholecystitis(2).
3. Abdominal pain
Gallstones are
relatively rare in children. At-risk populations include patients
suffering from hemolysis syndromes. Regardless of etiology, these
patients usually will present with postprandial abdominal pain, and
ultrasonography is the mainstay of diagnosis. However, some gallstones are radiopaque and can be visualized on plain abdominal radiography(3).
4. Other symptoms
In the study to evaluated the association between gallstones and abdominal symptoms, comparing two different study designs, researchers at the Maastricht University, showed that Gallstones were
associated with mid upper abdominal pain in the screening study, and
with mid upper abdominal pain, biliary pain, and colic (each
independently) in the clinical study. When these symptoms were absent (and only dyspeptic symptoms or food intolerance was present), gallstones
were not more common than expected from the general population
prevalence (estimated from the screening study)(4).
5. Etc.
A.2. Symptoms of severe case, include
1. Fever
2. Nausea and vomiting
3. Prolonged period of pain
4. Jaundice
5. Clay-colored stools
6. Etc.
B. Causes and Risk factors
B.1. Causes
High cholesterol or bilirubin in the bile
Gallstones are
precipitations of oversaturated bile fluid. They can develop in the
gallbladder and in the efferent bile ducts; they are very often
correlated with diseases of the gallbladder, bile ducts and neighboring
organs(5).
B.2. Risk factors
1. hypertriglyceridemia, overweight and insulin resistant
Patients with hypertriglyceridemia (HTG) - often overweight and insulin resistant - are at risk for gallstone disease(6).
2. Pregnancy and gender
Pregnant women(6b) and Elder are at higher risk to develop (specially, pigment stones in elder) gallstones(6a)
3. Haemoglobin E beta thalassaemia
in the study to determine whether this has a genetic basis we compared the bilirubin levels and frequency of gallstones in patients with different alleles of the UGT*1 gene, showed that the UGT*1 genotpe is of importance in the genesis of gallstones in this population of patients(7).
4. Obesity and weight loss
In the study to investigate the relation of obesity and weight loss to the formation of gallstones according to pertinent clinical and research issues, showed that during weight loss, particularly among the obese, an increased risk exists for symptomatic gallstone formation. This acute risk offers the opportunity to investigate the cause of gallstones and possibly to prevent them(8).
5. Diet
Diet with high in saturated fat and low in fiber increase the risk of gallstones as a result of increased cholesterol in the bile.
6. Ethnicity
Certain races may be at the increased of the development of gallstone such as American Indians, Mexican have a genetic predisposition to secrete high levels of cholesterol in bile.
7. Hormone replacement therapy in postmenopausal women and oral
contraceptives have also been described to be associated with an
increased risk for gallstone disease(8a).
C. Diagnosis
After completing the physical examination and family history, if gallstones are suspected, the tests which your doctor orders include
1. Blood tests
The aim of the blood test is to look for the signs of infection, obstruction, pancreatitis, jaundice, liver enzymes, etc.
2. Ultrasonography
The aim of the test is to look for the images of the abnormalltyof gallbladder and its surrounding area, including the thickened wall of the gallbladder when there is
cholecystitis, pancreatitis, enlarged gallbladder, bile duct obstruction, etc.
3. Computerized tomography (CT) scan
the aim of the CT scan to allow your doctor to visualize the gallbladder and its surrounding area, including gallstones, infection, rupture of gallbladder, etc..
4. Cholescintigraphy (HIDA scan)
The aim of the test is to diagnose the abnormal contraction of the gallbladder with the injection of with a small amount of radioactive material
5. Endoscopic retrograde cholangiopancreatography (ERCP)
With the local anesthesia and the use of a The endoscope, your doctor can visualize the gallstone and remove them if found.
6. Etc.
D. Complications and Diseases associated with gallstone
1. Spontaneous cholecystocutaneous fistula
Spontaneous perforation of gallbladder as a complication of biliary
stones may lead to a cholecystocutaneous abscess or fistula. The pathophysiology of this condition has been associated with increased
pressure in the gallbladder, secondary to biliary obstruction(9).
2. Jaundice
In the study to evaluate 56 patients with obstructive jaundice,
the presence or absence of calculi in the gallbladder has been
correlated with the cause of the obstruction. Seven of 23 patients with
obstruction caused by stone had no calculi in the gallbladder. Twelve of
33 patients with obstruction due to tumor also had gallstones. It was concluded that the presence of calculi in the gallbladder is a poor indicator of the cause of obstructive jaundice(10).
3. Others diseases associated with gallstones
a. In Children
In the review of the risk factors, complications, and outcomes of gallstones at our institution, particularly in those patients who are asymptomatic at the time of initial diagnosis, researchers at the The Hospital for Sick Children, Toronto, showed that at diagnosis, 50.5% of children were asymptomatic; these patients were
diagnosed at a mean age of 8.23 years. Compared with symptomatic
patients, they were less likely to have a hemolytic anemia but more
likely to have other risk factors, including cardiac surgery, leukemia
and lymphoma, short bowel syndrome, or exposure to total parenteral
nutrition or cephalosporins(11).
b. In Adult
Gallstones
cause various problems besides simple biliary colic and choplecystitis.
With chronicity of inflammation caused by gallstone obstruction of the
cystic duct, the gallbladder may fuse to the extrahepatic biliary tree,
causing Mirizzi syndrome, or fistulize into the intestinal tract,
causing so-called gallstone ileus. Stones may pass out of the
gallbladder and travel downstream through the common bile duct to
obstruct the ampulla of Vater resulting in gallstone pancreatitis, or
pass out of the gallbladder inadvertently during surgery, resulting in
the syndromes associated with lost gallstones(12).
E. Prevention
1. Vegetable
Vegetable protein may reduce the risk of cholelithiasis(19)
2. A low-fat, low-protein, high-carbohydrate or lowering of glycaemic index and the caloric reduction diet may reduce the risk of formation of gallstone formation(21)
3. Reduce intake of bad fat(23)
In the study of found that the type of dietary fat
habitually consumed can influence bile composition in humans. In
gallbladder, this influence was noted in the presence of more
concentrated bile in the olive oil group. However, this was not
translated into a modification of cholesterol saturation, which is
likely due to the fact that cholesterol gallstones were present by the time the dietary intervention started(22).
4. Nuts
Nuts (tree nuts and peanuts) are nutrient dense foods with complex
matrices rich in unsaturated fatty and other bioactive compounds:
high-quality vegetable protein, fiber, minerals, tocopherols,
phytosterols, and phenolic compounds According to the study by Dr, Ros E nuts are likely to beneficially impact health outcomes.
Epidemiologic studies have associated nut consumption with a reduced
incidence of coronary heart disease and gallstones in both genders and diabetes in women(20).
5. Wheat bran
There is a study of 10 patients with probable cholesterol gallstones
took bran supplements for 4-6 weeks, their gallbladder bile aspirated
from the duodenum became less saturated with cholesterol(24).
6. Others
Some researchers suggested that intake of high energy, simple sugar and saturated fat favors gallstone formation. Fiber and moderate consumption of alcohol reduce the risk(25).
F. Treatment
F.1. In conventional medicine perspective
1. Cholecystectomy
No treatment for people who have developed galldtones but with no system, otherwise, surgery to remove the gallbladder may be necessary. Cholecystectomy is the surgical removal of the symptomatic gallbladder. In the sugery, It is the most common method for treating symptomatic gallstones, other surgeries include the laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.
2. Others
a. Some researchers suggested for the treatment of gallstones
in patients with normal stonefree bile ducts, new modalities have been
developed besides the classical cholecystectomy and the oral litholysis.
The interventional procedures (local litholysis, extracorporeal
shockwave lithotripsy, combination of shockwave lithotripsy and local
litholysis, cholecystostomy and extra- or intracorporeal lithotripsy) do
not need a narcosis and can be applied even in high-risk patients.
Because the gallbladder itself is not removed, the recurrence rate after
all these interventions is rather high. The new operative procedures
(laparoscopic cholecystectomy, mini-laparotomy cholecystectomy) are
definitive solutions for stone disease, but must be performed mostly in
narcosis(13).
b. Today, cholecystectomy was still the most frequent method of treatment
for symptomatic cholecystolithiasis (n = 1369) with low morbidity
(4.3%) and lethality (0.28%). Probably less than 20% of all cases
fulfill the strict selection criteria for extracorporeal shock wave
lithotripsy (ESWL). All alternative methods of treatment
in which the gallbladder is preserved have an increased risk for gall
stone recurrence. Only after the long-term follow-up results of ESWL are
known, the recurrence rate can be assessed. In most cases, bile duct
stones (n = 417) were removed by endoscopy, if necessary in combination
with ESWL (n = 310, stone removal: 95%, lethality: 0.3%). However, in
low risk patients with concurrent cholecystolithiasis surgery was still
the method of choice (n = 107, stone removal: 96%, lethality: 0/107)(14).
F.2. In herbal medicine perspective
1. Fenugreek seeds and onion
In the study to evaluate the antilithogenic effect of a combination of dietary fenugreek seeds and onion, researchers at the Central Food Technological Research Institute, found that hepatic lipid peroxides were reduced by 19-22% and 39-45% with fenugreek, onion and their combination included in the diet
along with the HCD. Increased accumulation of fat in the liver and
inflammation of the gallbladder membrane produced by HCD were reduced by
fenugreek, onion and their combination. The antilithogenic influence
was highest with fenugreek alone, and the presence of onion along with
it did not further increase this effect(15).
2. Capsaicin and curcumin
In the study of the efficacy of capsaicin and curcumin in cholesterol gallstones induced by feeding mice a high-cholesterol (0.5%) diet for 10 weeks, found that the capsaicin and curcumin combination did not have an additive
influence in reducing the incidence of cholesterol gallstones in mice,
their combination nevertheless was more beneficial in enhancing the
activity of hepatic antioxidant enzyme ─ glutathione reductase in the
lithogenic situation. The antioxidant effects of dietary spice compounds
are consistent with the observed reduction in cholesterol gallstones
formed under lithogenic condition(16).
3. Garlic and onion
The Central Food Technological Research Institute has reported the study of the health beneficial potential of dietary garlic and onion in reducing the incidence and severity of cholesterol gallstone (CGS)with the induced CGS in mice with a lithogenic diet for 10 weeks, they were maintained on basal diets containing 0.6% dehydrated garlic or 2% dehydrated onion for a further 10 weeks(26). Others suggested that dietary allium spices exerted antilithogenic influence by decreasing the
cholesterol hyper-secretion into bile and increasing the bile acid
output thus decreasing the formation of lithogenic bile in experimental
mice(27).
4. Milk thistle
There is a study indicated that after intake of milk thistle bile duct hyperplasia were significantly decreased in
50,000 ppm males and in all exposed groups of females, and the incidence
of mixed inflammatory cell infiltration was significantly decreased in
50,000 ppm males(28).
5. Etc.
F.3. In traditional Chinese perpective
1. Traditional Chinese herbs
for nourishing the liver (Yanggan Lidan Granule (YGLDG))
In the study of Eighty guinea pigs randomly divided into four groups, which were normal control group, untreated group, nourishing-liver Chinese drug (NLCD) group and ursodeoxycholic acid (UDCA) group, with 20 guinea pigs in each group, gallstones were induced in the guinea pigs of the latter 3 groups by the feed of diet inducing cholelithiasis with high cholesterol, while the corresponding medicines were used in NLCD group and UDCA group for prevention and treatment for 7 weeks, showed that the [Ca(2+)]i in gallbladder cells is the important factor for contractile function of gallbladder and the information of gallstones. Traditional Chinese herbs
for nourishing the liver may significantly increase the [Ca(2+)]i in
gallbladder cells to facilitate contraction of the smooth muscle cells
of gallbladder and relieve the cholestatis(17).
Other study to explore the effects of Yanggan Lidan Granule (YGLDG), a compound traditional Chinese
herbal medicine for nourishing liver and improving choleresis, on the
rate of gallstone formation and content of plasma cholecystokinin in
guinea pigs with induced cholesterol gallstones. indicated that YGLDG can significantly decrease the rate of gallstone formation in
guinea pigs. It may be related to elevating the content of CCK in the
plasma(18).
2. Ingredients of Yanggan Lidan Granule (YGLDG)
a. Bai Shao tonifies liver Yin,
b. Chen Pi,
c. Gao Qi Zi tonifies liver Yin
d. He shou wu tonifies liver Yin
e. Gan Cao
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/22914239
(2) http://www.ncbi.nlm.nih.gov/pubmed/9200296
(3) http://www.ncbi.nlm.nih.gov/pubmed/22888958
(4) http://www.ncbi.nlm.nih.gov/pubmed/9802450
(5) http://www.ncbi.nlm.nih.gov/pubmed/423995
(6) http://www.ncbi.nlm.nih.gov/pubmed/20699090
(6a) http://www.ncbi.nlm.nih.gov/pubmed/7771432
(6b) http://www.ncbi.nlm.nih.gov/pubmed/17103289
(7) http://www.ncbi.nlm.nih.gov/pubmed/11425418
(8) http://www.ncbi.nlm.nih.gov/pubmed/8214980
(8a) http://www.ncbi.nlm.nih.gov/pubmed/17103289
(9) http://www.ncbi.nlm.nih.gov/pubmed/22794521
(10) http://www.ncbi.nlm.nih.gov/pubmed/7434173
(11) http://www.ncbi.nlm.nih.gov/pubmed/20118803
(12) http://www.ncbi.nlm.nih.gov/pubmed/18992599
(13) http://www.ncbi.nlm.nih.gov/pubmed/2028140
(14) http://www.ncbi.nlm.nih.gov/pubmed/2721300
(15) http://www.ncbi.nlm.nih.gov/pubmed/21756271
(16) http://www.ncbi.nlm.nih.gov/pubmed/21609281
(17) http://www.ncbi.nlm.nih.gov/pubmed/17352876
(18) http://www.ncbi.nlm.nih.gov/pubmed/18405610
(19) http://www.ncbi.nlm.nih.gov/pubmed/1503808
(20) http://www.ncbi.nlm.nih.gov/pubmed/22254047
(21) http://www.ncbi.nlm.nih.gov/pubmed/14619611
(22) http://www.ncbi.nlm.nih.gov/pubmed/15797676
(23) http://www.ncbi.nlm.nih.gov/pubmed/1398503
(24) http://www.ncbi.nlm.nih.gov/pubmed/941893
(25) http://www.ncbi.nlm.nih.gov/pubmed/15190042
(26) http://www.ncbi.nlm.nih.gov/pubmed/20153000
(27) http://www.ncbi.nlm.nih.gov/pubmed/18983715
(28) http://www.ncbi.nlm.nih.gov/pubmed?term=Milk%20thistle%20and%20gallstone
Thursday, October 25, 2012
Friday, October 19, 2012
Kidney stones (Renal calculus)
Kidney stones is a composed of mineral salts formed in the kidneys. Men account for the 80% of those with kidney stones and are at risk of the formings between 30 and 40 years of age. About 75% of kidney stones are calcium stones.
I. Symptoms
II. Causes and Risk factors
A. Causes
1. Dehydration
Dehydration or strenuous exercise without adequate fluid can cause the forming of kidney stones as a result of low levels of urine pH (below 5.5)(1).
2. Ramadan fasting ( food restriction)
Ramadan fasting are associated with risk of kidney stones forming. In the study to evaluate the effects of fluid and food restriction in Ramadan fasting on urinary factors in kidney and urinary calculus formation, researchers at the Shahid Beheshti University of Medical Sciences, found that fasting during Ramadan has different effects on total excretion and concentrations of urinary precipitate and inhibitory factors contributing to calculus formation(2).
3. Rotavirus infection
There is a report of 4 patients with RV infection who developed postrenal renal failure induced by urinary tract obstruction with uroammoniac calculi or crystals... Uric acid stone formation was considered to have originated from the low pH caused by dehydration and the increase of urinary uric acid excretion from damaged cells(3).
4. Calcium
In the study to explore the relationship among intestinal fractional calcium absorption, calcium intake and nephrolithiasis in a prospective cohort of 9,704 postmenopausal women recruited from population based listings in 1986 and followed for more than 20 years, showed that fractional calcium absorption is higher in women with a history of nephrolithiasis. Higher intestinal fractional calcium absorption is associated with a greater risk of historical nephrolithiasis. Dietary and supplemental calcium decrease fractional calcium absorption, and may protect against nephrolithiasis(3a).
5. Gastrointestinal lipase inhibitor
Intestinal malabsorption can cause urinary stone disease via enteric hyperoxaluria. The use of lipase inhibitors, especially under a diet rich in oxalate alone or associated with fat, leads to a significant and marked increase in urinary oxalate and a slight reduction in uCa and uMg that, taken together, resulted in an increase in AP (CaOx) index(rat), elevating the risk of stone formation(3b).
6. High fat intake
A comparison of the dietary intake per kilogram body weight in each group was made using standard statistical procedures. None of the nutrient intakes showed a significant difference, but dietary fibre intake and the percentage of energy provided by carbohydrate were consistently higher in the control group, whereas the percentage of energy provided by fat was consistently higher in the renal stone group(3c).
7. Vitamins
In the study of a total of 1078 incident cases of kidney stones was documented during the 14-yr follow-up period. A high intake of vitamin B6 was inversely associated with risk of stone formation. After adjusting for other dietary factors, the relative risk of incident stone formation for women in the highest category of B6 intake (> or =40 mg/d) compared with the lowest category (<3 mg/d) was 0.66 (95% confidence interval, 0.44 to 0.98). In contrast, vitamin C intake was not associated with risk. The multivariate relative risk for women in the highest category of vitamin C intake (> or =1500 mg/d) compared with the lowest category (<250 mg/d) was 1.06 (95% confidence interval, 0.69 to 1.64). Large doses of vitamin B6 may reduce the risk of kidney stone formation in women. Routine restriction of vitamin C to prevent stone formation appears unwarranted(3d).
8. Etc.
B. Risk factors
1. Gender
If you are men, you are at higher risk to develop kidney stones. In the study to determine gender differences in the symptomatic presentation of kidney and ureteral stones among the Hispanic population and compared it with presentation in the Caucasian population, found that the male-to-female ratio of the symptomatic patients with kidney stones was 1.48 for both Hispanic and Caucasian patients. The male-to-female ratio for ureteral stones was 1.06 and 2.48 for the Hispanic and Caucasian patients, respectively (P < 0.05)(4).
2. Family history
You are more likely to develop (more) kidney stones, if one the your directed family member have itor you already have them as a result of genetic factors, environmental exposures, or others(5).
3. Hyperuricemia
If you have hyperuricemia, you are at invreased risk to develop kidney stone as the result of the elevation of uric acid levels. Uric acid stones occur in 10% of all kidney stones and are the second most-common cause of urinary stones after calcium oxalate and calcium phosphate calculi(6).
4. Pregnancy
Although the risk is low, increased progesterone levels and decreased fluid intake during pregnancy may be associated with the increased risk of the development of kidney stones. According to the study of 22,843 newborns or fetuses with CAs, 69 (0.30%) had mothers with KS during pregnancy. Of 38,151 matched control newborns without any abnormalities, 147 (0.39%) had KS during pregnancy. KS were associated with an adjusted prevalence odds ratio (POR) with 95% CI of 0.8, 0.6-1.0 for CAs(7).
5. Low urine pH (below 5.5)
For uric acid crystallization and stone formation, low urine pH (below 5.5) is a more important risk factor than increased urinary uric acid excretion. Main causes of low urine pH are tubular disorders (including gout), chronic diarrheal states or severe dehydration(8).
6. Infection of urinary track
In the study of total of 100 kidney stone formers (59 males and 41 females) admitted for elective percutaneous nephrolithotomy who were recruited and microorganisms isolated from catheterized urine and cortex and nidus of their stones by Faculty of Associated Medical Science, Khon Kaen University, showed that from 100 stone formers recruited, 36 cases had a total of 45 bacterial isolates cultivated from their catheterized urine and/or stone matrices. Among these 36 cases, chemical analysis by Fourier-transformed infrared spectroscopy revealed that 8 had the previously classified 'infection-induced stones', whereas the other 28 cases had the previously classified 'metabolic stones'. Calcium oxalate (in either pure or mixed form) was the most common and found in 64 and 75% of the stone formers with and without bacterial isolates, respectively. Escherichia coli was the most common bacterium (approximately one-third of all bacterial isolates) found in urine and stone matrices (both nidus and periphery). Linear regression analysis showed significant correlation (r = 0.860, P < 0.001) between bacterial types in urine and stone matrices. Multidrug resistance was frequently found in these isolated bacteria. Moreover, urea test revealed that only 31% were urea-splitting bacteria, whereas the majority (69%) had negative urea test(9).
7. Water hardness
In the study to evaluate whether the hardness of extra meal drinking water modifies the risk for calcium stones, showed that the main urinary risk factors for calcium stones, were measured in 18 patients with idiopathic nephrolithiasis, maintained at fixed dietary intake of calcium (800 mg/day), after drinking for 1 week 2 liters per day, between meals, of tap water and at the end of 1 week of the same amount of bottled hard (Ca2+ 255 mg/l) or soft (Ca2+ 22 mg/l, Fiuggi water) water, in a double-blind randomized, crossover fashion(10).
8. Obesity and diabetes
Obesity and diabetes were strongly associated with a history of kidney stones in multivariable models. The cross-sectional survey design limits causal inference regarding potential risk factors for kidney stones(11).
9. Etc.
III. Diagnosis
If you are experience tenderness over the back and groin or pain in the genital area without an obvious cause, it can be renal colic. After a complete physical examination and recorded family history, the most common test which your doctor order is CT scan.
1. CT scan and Ultrasound
The aim of CT scan is to detect the stones or obstruction within the urinary tract.In pregnant women, CT scan can be replaced by ultrasound to reduce the risk of radiation. Helical (also called spiral) computed tomography (CT) is considered as the best to locate and reveal the degree to which the stone is blocking the urinary tract.
2. Urinalysis
Urinalysis is important to detect blood or pus in the urine and determine whether or not symptoms are present.
According to the study by University of Chicago Pritzker School of Medicine, Current diagnostic evaluation of recurrent Ca oxalate nephrolithiasis should be conducted while the patients follow their usual diets and includes the following:
1. Analysis of stone composition by polarization microscopy.
2. Measurement of serum Ca, phosphate, uric acid, 1,25(OH)2D3, and creatinine.
3. Twenty-four-hour urine collection for an analysis of volume, pH, and excretion of Ca, phosphorus, magnesium, uric acid, citrate, sodium, oxalate, and creatinine(12).
IV. Prevention
The do's and do not list
1. Fluid intake, protein and sodium restriction, and thiazide will be effective in ICSFs and IPSFs by decreasing urine calcium concentration and CaOx and CaP SS and may also decrease plaque formation by increased PT calcium reabsorption. Citrate may be detrimental for IPSFs if urine pH rises greatly, increasing CaP SS. Future trials should examine the question of appropriate treatment for IPSFs(13).
2. Moderate exercise
Moderate exercise to reduce the loss of fluid. If you involve in the extreme exercise, please remember to enough fluid to avoid dehydration.
3. Prevent vitamin overdose as they can cause the forming of kidney stones.
4. If you live in far North with water hardness, use water filter
5. If you are over weight or obese, lose weight
6. Reduced consumption of grapefruit juice cola drinks.
Study showed that grapefruit juice and cola drinks significantly (p=0.021) increased urinary excretion of citrate (25.8+/-9.3 vs 18.7+/-6.2 mg/h), calcium (6.7+/-4.3 vs 3.3+/-2.3 mg/h, p=0.015) and magnesium (2.9+/-1.5 vs 1.0+/-0.7 mg/h, p=0.003) and in the prevention of calcium renal stones a reduced sugar content is desirable to avoid the increase of urinary calcium due to the effect of sugar supplementation(14).
7. Drink more juices (organic)
Researchers at the University of Bonn, in the study of influence of grapefruit-, orange- and apple-juice consumption on urinary variables and risk of crystallization, indicated that due to an increased pH value and an increased citric acid excretion after consumption of each juice, the RSCaOx decreased statistically significantly (P<0.05) for grapefruit juice, but not significantly for orange and apple juice. The BONN risk index yielded a distinct decrease in the crystallization risk. We showed that both grapefruit juice and apple juice reduce the risk of CaOx stone formation at a magnitude comparable with the effects obtained from orange juice(15).
7. Increased intake of fruits with high in magnesium and potassium
Grapefruit juice significantly (p=0.021) increased urinary excretion of citrate (25.8+/-9.3 vs 18.7+/-6.2 mg/h), calcium (6.7+/-4.3 vs 3.3+/-2.3 mg/h, p=0.015) and magnesium (2.9+/-1.5 vs 1.0+/-0.7 mg/h, p=0.003). Citrus fruit juices could represent a natural alternative to potassium citrate in the management of nephrolithiasis(16).
8. Reduce intake of foods containing high amount of oxalate such as spinach, rhubarb, nuts, wheat bran, etc.
9. Others
According to the study of Dietary Factors and Risk of Kidney Stone: A Case-Control Study in Southern China, researchers at the Nanfang Hospital, Guangzhou, indicated that positive associations of kidney stones include consumption of grains (odds ratio [OR] = 2.08; 95% confidence interval [CI] = 1.08, 4.02) and bean products (OR = 3.50; 95% CI = 1.61, 7.59) in women. The variable "fluid drinking" showed a significant protective effect against kidney stones in men (OR = 0.57; 95% CI = 0.36, 0.88). Consuming leafy vegetables more than 3 times per day was positively associated with stones in both men and women (OR = 2.02; 95% CI = 1.04, 3.91 and OR = 3.86; 95% CI = 1.48, 10.04, respectively)(17).
V. Treatment
A. In conventional medicine perspective
Most kidney with diameter less than 5 mm (0.20 in) may pass through the urinary tract through urination within days of the onset of symptoms
A.1. Medications
The aims of medication is to manage pain or assist the speed up the spontaneous passage of ureteral calculi
1. Analgesia
Medication used to relieve pain.
2. Expulsion therapy
a. In the study to evaluate the efficacy of alfuzosin as medical expulsive therapy for distal ureteral stone passage od a total of 76 patients with a distal ureteral calculus, showed that the overall spontaneous stone passage rate was 75%, including 77.1% for placebo and 73.5% for alfuzosin (p = 0.83). Mean +/- SD time needed to pass the stone was 8.54 +/- 6.99 days for placebo vs 5.19 +/- 4.82 days for alfuzosin. (p = 0.003). There was no difference in the size or volume of stones that passed spontaneously between the placebo and alfuzosin arms, as measured on baseline computerized tomography (4.08 +/- 1.17 and 3.83 +/- 0.95 mm, p = 0.46) and by a digital caliper after stone expulsion (3.86 +/- 1.76 and 3.91 +/- 1.06 mm, respectively, p = 0.57). When comparing the improvement from the baseline pain score, the alfuzosin arm experienced a greater decrease in pain score in the days after the initial emergency department visit to the date of stone passage (p = 0.0005)(18).
A.2. Non invasive treatment and surgery
Extracorporeal shockwave lithotripsy does not require anaesthesia and requires little analgesia so that treatment can be given on an outpatient basis, and there is no wound to heal. Only a small puncture site is needed for percutaneous endoscopic lithotomy, and with the advent of prophylactic antibiotics there are few complications. Of renal stones, about 85% can now be successfully treated by extracorporeal lithotripsy alone, and almost all of the stones too large or hard for lithotripsy can be treated endoscopically, with ultrasonic or electrohydraulic probes being used to fragment the stone(19).
A.3. Recurrent treatments
2.1. Recurrent cystine renal stones
In the report of using ureterorenoscopy (URS) for the treatment of recurrent renal cystine stones. From 2003 to 2007, 10 patients (4 males and 6 females) with one or multiple recurrent renal cystine stones underwent URS. Overall, 21 procedures have been performed. Mean maximum diameter of stones was 11.2 mm (range 5-30 mm). Either 8-9.5 F semirigid or 7.9 F flexible ureteroscopes were used. In 6 cases, stones were removed using a basket; in 9 procedures laser lithotripsy with flexible scope was performed; in 6 cases renal calculi were pulled down in the ureter using flexible instrument and then shattered with laser introduced by semirigid instrument. Stone-free status was defined as the absence of any residual fragment. A complete stone clearance was obtained in 15 out of 21 procedures (71%). In 5 cases (24%) significant residual fragments occurred; in the remaining case (5%) URS was ineffective. In 5 out of these unsuccessful procedures, stone clearance was obtained with auxiliary treatments. The last patient has not been treated yet(20).
2.2. In general
Patients with kidney stones are highly motivated to prevent recurrence and were more amenable to fluid intake change than to another dietary or pharmaceutical intervention. Barriers preventing fluid intake success aligned into 3 progressive stages.
a. Stage 1 barriers included not knowing the benefits of fluid or not remembering to drink.
b. Stage 2 barriers included disliking the taste of water, lack of thirst and lack of availability.
c. Stage 3 barriers included the need to void frequently and related workplace disruptions.
Tailoring fluid intake counseling based on patient stage may improve fluid intake behavior(21).
B. In herbal medicine perspective
1. Asparagus racemosus Willd
In the study of the ethanolic extract of Asparagus racemosus Willd. for its inhibitory potential on lithiasis (stone formation), induced by oral administration of 0.75% ethylene glycolated water to adult male albino Wistar rats for 28 days, showed that the histopathological findings also showed signs of improvement after treatment with the extract. All these observations provided the basis for the conclusion that this plant extract inhibits stone formation induced by ethylene glycol treatment(22).
2. Goldenrod
Investigations in molecular pharmacology could show new mechanisms responsible for the biological effect of natural product from goldenrod extracts. The use of such herbal preparations with a rather complex action spectrum (anti-inflammatory, antimicrobial, diuretic, antispasmodic, analgesic) is especially recommended for treatment of infections and inflammations, to prevent formation of kidney stones and to help remove urinary gravel. This therapy is safe at a reasonable price and does not show drug-related side-effects, according to the study of the Institut für Pharmazie der Freien Universität Berlin, Berlin(23).
3. Other herbs
In the study of the effects of seven plants with suspected application to prevent and treat stone kidney formation (Verbena officinalis, Lithospermum officinale, Taraxacum officinale, Equisetum arvense, Arctostaphylos uva-ursi, Arctium lappa and Silene saxifraga) in female Wistar rats, showed that beneficial effects caused by these herb infusions on urolithiasis can be attributed to some disinfectant action, and tentatively to the presence of saponins. Specifically, some solvent action can be postulated with respect to uric stones or heterogeneous uric nucleus, due to the basifying capacity of some herb infusions. Nevertheless, for all the mentioned beneficial effects, more effective and equally innocuous substances are well known(24).
4. Etc.
C. In the traditional Chinese medicine perspective
C.1. According to the article of Chinese medicine Hospital for Chronic and Difficult diseases(25), traditional Chinese medicine defined kidney stones is a condition caused by
1. Qi stagnation
a. The aim of the herbal treatment is to Promotethe circulation of qi, inducing diuresis, relieving strangury and removing the stones.
b. Herbal formula: Modified Pyrrosia Decoction
Lysimachia, Pyrrosia leaf, Plantago seed, Cluster mallow fruit, Oriental water plantain rhizome, Citron fruit, Vaccaria seed, Radish seed and Rhubarb.
2. Damp-Heat Pattern
a. The aim of the herbal formula is to clear heat and dampness, relieve strangury and remove the stones.
b. Herbal formula: Modified Eight Health Restoring Powder
Lysimachia, Prostrate knotweed, Chinese pink herb, Talc, Phellodendron bark, Capejasmine fruit and Plantago seed , Rhubarb and Licorice root tip
3. Kidney deficiency
a. The aim of the herb used to treat kidney stones as a result of kidney deficiency is to tonify qi, reinforce the kidney, relieve stranguria and remove the stones.
b. Herbal formula: Modified Kidney-Reinforcing Decoction
Prepared rehmannia root, Wolfberry fruit, Dogwood fruit, Achyranthes root, Bighead atractylodes. Rhizome eucommia bark, Cinnamon bark, Pilose asiabell root, Lysimachia and Climbing fern spore
C.2. Chinese herbal formula Wu Ling San (Poria, Rhizoma Alismatis, Polyporus, Cortex Cinnamomi, Rhizoma Atractylodis Macrocephalae (stir-baked))
In the study to determine the effects of a traditional Chinese herbal formula, Wulingsan (WLS), on renal stone prevention using an ethylene glycol-induced nephrocalcinosis rat model. Forty-one male Sprague-Dawley (SD) rats were divided into four groups. Group 1 (n=8) was the normal control; group 2 (n=11) served as the placebo group, and received a gastric gavage of starch and 0.75% ethylene glycol (EG) as a stone inducer; group 3 received EG and a low dose of WLS (375 mg/kg); and group 4 received EG and a high dose of WLS (1,125 mg/kg), found that the rats of placebo group gained the least significant body weight; in contrast, the rats of WLS-fed groups could effectively reverse it. The placebo group exhibited lower levels of free calcium (p=0.059) and significantly lower serum phosphorus (p=0.015) in urine than WLS-fed rats. Histological findings of kidneys revealed tubular destruction, damage and inflammatory reactions in the EG-water rats. The crystal deposit scores dropped significantly in the WLS groups, from 1.40 to 0.46 in the low-dose group and from 1.40 to 0.45 in the high-dose group. Overall, WLS effectively inhibited the deposition of calcium oxalate (CaOx) crystal and lowered the incidence of stones in rats (p=0.035). In conclusion, WLS significantly reduced the severity of calcium oxalate crystal deposits in rat kidneys, indicating that Wulingsan may be an effective antilithic herbal formula(26).
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Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/12649987
(1a) http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/stones_in_the_urinary_tract/stones_in_the_urinary_tract.html?qt=&sc=&alt=
(2) http://www.ncbi.nlm.nih.gov/pubmed/22218117
(3) http://www.ncbi.nlm.nih.gov/pubmed/20420802
(3a) http://www.ncbi.nlm.nih.gov/pubmed/22341269
(3b) http://www.ncbi.nlm.nih.gov/pubmed/15253722
(3c) http://www.ncbi.nlm.nih.gov/pubmed/6269684
(3d) http://www.ncbi.nlm.nih.gov/pubmed/10203369
(4) http://www.ncbi.nlm.nih.gov/pubmed/15865513
(5) http://www.ncbi.nlm.nih.gov/pubmed/9335385
(6) http://www.ncbi.nlm.nih.gov/pubmed/15493118
(7) http://www.ncbi.nlm.nih.gov/pubmed/17096158
(8) http://www.ncbi.nlm.nih.gov/pubmed/12649987
(9) http://www.ncbi.nlm.nih.gov/pubmed/22461670
(10) http://www.ncbi.nlm.nih.gov/pubmed/9873217
(11) http://www.ncbi.nlm.nih.gov/pubmed/22498635
(12) http://www.ncbi.nlm.nih.gov/pubmed/7671093
(13) http://www.ncbi.nlm.nih.gov/pubmed/21825103
(14) http://www.ncbi.nlm.nih.gov/pubmed/12408462
(15) http://www.ncbi.nlm.nih.gov/pubmed/12908889
(16) http://www.ncbi.nlm.nih.gov/pubmed/12408462
(17) http://www.ncbi.nlm.nih.gov/pubmed/22658934
(18) http://www.ncbi.nlm.nih.gov/pubmed/18423747
(19) http://www.ncbi.nlm.nih.gov/pubmed/8274898
(20) http://www.ncbi.nlm.nih.gov/pubmed/21193905
(21) http://www.ncbi.nlm.nih.gov/pubmed/22341296
(22) http://www.ncbi.nlm.nih.gov/pubmed?term=asparagus%20root%20and%20kidney%20stones
(23) http://www.ncbi.nlm.nih.gov/pubmed/15638071
(24) http://www.ncbi.nlm.nih.gov/pubmed/7860196
(25) http://www.tcmtreatment.com/images/diseases/urinary-calculus.htm
(26) http://www.ncbi.nlm.nih.gov/pubmed/18040675
I. Symptoms
Some people with kidney stones may not experience any symptom at all. Renal colic is
characterized by an excruciating intermittent pain, usually in the flank
(the area between the ribs and hip), that spreads across the abdomen,
often to the genital area and inner thigh. The pain tends to come in
waves, gradually increasing to a peak intensity, then fading, over about
20 to 60 minutes. The pain may radiate down the abdomen toward the
groin or testis or vulva.
Other symptoms include nausea and vomiting,
restlessness, sweating, and blood in the urine. A person may have an
urge to urinate frequently, particularly as a stone passes down the
ureter. Chills, fever, and abdominal distention sometimes occur.(1a)
A. Causes
1. Dehydration
Dehydration or strenuous exercise without adequate fluid can cause the forming of kidney stones as a result of low levels of urine pH (below 5.5)(1).
2. Ramadan fasting ( food restriction)
Ramadan fasting are associated with risk of kidney stones forming. In the study to evaluate the effects of fluid and food restriction in Ramadan fasting on urinary factors in kidney and urinary calculus formation, researchers at the Shahid Beheshti University of Medical Sciences, found that fasting during Ramadan has different effects on total excretion and concentrations of urinary precipitate and inhibitory factors contributing to calculus formation(2).
3. Rotavirus infection
There is a report of 4 patients with RV infection who developed postrenal renal failure induced by urinary tract obstruction with uroammoniac calculi or crystals... Uric acid stone formation was considered to have originated from the low pH caused by dehydration and the increase of urinary uric acid excretion from damaged cells(3).
4. Calcium
In the study to explore the relationship among intestinal fractional calcium absorption, calcium intake and nephrolithiasis in a prospective cohort of 9,704 postmenopausal women recruited from population based listings in 1986 and followed for more than 20 years, showed that fractional calcium absorption is higher in women with a history of nephrolithiasis. Higher intestinal fractional calcium absorption is associated with a greater risk of historical nephrolithiasis. Dietary and supplemental calcium decrease fractional calcium absorption, and may protect against nephrolithiasis(3a).
5. Gastrointestinal lipase inhibitor
Intestinal malabsorption can cause urinary stone disease via enteric hyperoxaluria. The use of lipase inhibitors, especially under a diet rich in oxalate alone or associated with fat, leads to a significant and marked increase in urinary oxalate and a slight reduction in uCa and uMg that, taken together, resulted in an increase in AP (CaOx) index(rat), elevating the risk of stone formation(3b).
6. High fat intake
A comparison of the dietary intake per kilogram body weight in each group was made using standard statistical procedures. None of the nutrient intakes showed a significant difference, but dietary fibre intake and the percentage of energy provided by carbohydrate were consistently higher in the control group, whereas the percentage of energy provided by fat was consistently higher in the renal stone group(3c).
7. Vitamins
In the study of a total of 1078 incident cases of kidney stones was documented during the 14-yr follow-up period. A high intake of vitamin B6 was inversely associated with risk of stone formation. After adjusting for other dietary factors, the relative risk of incident stone formation for women in the highest category of B6 intake (> or =40 mg/d) compared with the lowest category (<3 mg/d) was 0.66 (95% confidence interval, 0.44 to 0.98). In contrast, vitamin C intake was not associated with risk. The multivariate relative risk for women in the highest category of vitamin C intake (> or =1500 mg/d) compared with the lowest category (<250 mg/d) was 1.06 (95% confidence interval, 0.69 to 1.64). Large doses of vitamin B6 may reduce the risk of kidney stone formation in women. Routine restriction of vitamin C to prevent stone formation appears unwarranted(3d).
8. Etc.
B. Risk factors
1. Gender
If you are men, you are at higher risk to develop kidney stones. In the study to determine gender differences in the symptomatic presentation of kidney and ureteral stones among the Hispanic population and compared it with presentation in the Caucasian population, found that the male-to-female ratio of the symptomatic patients with kidney stones was 1.48 for both Hispanic and Caucasian patients. The male-to-female ratio for ureteral stones was 1.06 and 2.48 for the Hispanic and Caucasian patients, respectively (P < 0.05)(4).
2. Family history
You are more likely to develop (more) kidney stones, if one the your directed family member have itor you already have them as a result of genetic factors, environmental exposures, or others(5).
3. Hyperuricemia
If you have hyperuricemia, you are at invreased risk to develop kidney stone as the result of the elevation of uric acid levels. Uric acid stones occur in 10% of all kidney stones and are the second most-common cause of urinary stones after calcium oxalate and calcium phosphate calculi(6).
4. Pregnancy
Although the risk is low, increased progesterone levels and decreased fluid intake during pregnancy may be associated with the increased risk of the development of kidney stones. According to the study of 22,843 newborns or fetuses with CAs, 69 (0.30%) had mothers with KS during pregnancy. Of 38,151 matched control newborns without any abnormalities, 147 (0.39%) had KS during pregnancy. KS were associated with an adjusted prevalence odds ratio (POR) with 95% CI of 0.8, 0.6-1.0 for CAs(7).
5. Low urine pH (below 5.5)
For uric acid crystallization and stone formation, low urine pH (below 5.5) is a more important risk factor than increased urinary uric acid excretion. Main causes of low urine pH are tubular disorders (including gout), chronic diarrheal states or severe dehydration(8).
6. Infection of urinary track
In the study of total of 100 kidney stone formers (59 males and 41 females) admitted for elective percutaneous nephrolithotomy who were recruited and microorganisms isolated from catheterized urine and cortex and nidus of their stones by Faculty of Associated Medical Science, Khon Kaen University, showed that from 100 stone formers recruited, 36 cases had a total of 45 bacterial isolates cultivated from their catheterized urine and/or stone matrices. Among these 36 cases, chemical analysis by Fourier-transformed infrared spectroscopy revealed that 8 had the previously classified 'infection-induced stones', whereas the other 28 cases had the previously classified 'metabolic stones'. Calcium oxalate (in either pure or mixed form) was the most common and found in 64 and 75% of the stone formers with and without bacterial isolates, respectively. Escherichia coli was the most common bacterium (approximately one-third of all bacterial isolates) found in urine and stone matrices (both nidus and periphery). Linear regression analysis showed significant correlation (r = 0.860, P < 0.001) between bacterial types in urine and stone matrices. Multidrug resistance was frequently found in these isolated bacteria. Moreover, urea test revealed that only 31% were urea-splitting bacteria, whereas the majority (69%) had negative urea test(9).
7. Water hardness
In the study to evaluate whether the hardness of extra meal drinking water modifies the risk for calcium stones, showed that the main urinary risk factors for calcium stones, were measured in 18 patients with idiopathic nephrolithiasis, maintained at fixed dietary intake of calcium (800 mg/day), after drinking for 1 week 2 liters per day, between meals, of tap water and at the end of 1 week of the same amount of bottled hard (Ca2+ 255 mg/l) or soft (Ca2+ 22 mg/l, Fiuggi water) water, in a double-blind randomized, crossover fashion(10).
8. Obesity and diabetes
Obesity and diabetes were strongly associated with a history of kidney stones in multivariable models. The cross-sectional survey design limits causal inference regarding potential risk factors for kidney stones(11).
9. Etc.
III. Diagnosis
If you are experience tenderness over the back and groin or pain in the genital area without an obvious cause, it can be renal colic. After a complete physical examination and recorded family history, the most common test which your doctor order is CT scan.
1. CT scan and Ultrasound
The aim of CT scan is to detect the stones or obstruction within the urinary tract.In pregnant women, CT scan can be replaced by ultrasound to reduce the risk of radiation. Helical (also called spiral) computed tomography (CT) is considered as the best to locate and reveal the degree to which the stone is blocking the urinary tract.
2. Urinalysis
Urinalysis is important to detect blood or pus in the urine and determine whether or not symptoms are present.
According to the study by University of Chicago Pritzker School of Medicine, Current diagnostic evaluation of recurrent Ca oxalate nephrolithiasis should be conducted while the patients follow their usual diets and includes the following:
1. Analysis of stone composition by polarization microscopy.
2. Measurement of serum Ca, phosphate, uric acid, 1,25(OH)2D3, and creatinine.
3. Twenty-four-hour urine collection for an analysis of volume, pH, and excretion of Ca, phosphorus, magnesium, uric acid, citrate, sodium, oxalate, and creatinine(12).
IV. Prevention
The do's and do not list
1. Fluid intake, protein and sodium restriction, and thiazide will be effective in ICSFs and IPSFs by decreasing urine calcium concentration and CaOx and CaP SS and may also decrease plaque formation by increased PT calcium reabsorption. Citrate may be detrimental for IPSFs if urine pH rises greatly, increasing CaP SS. Future trials should examine the question of appropriate treatment for IPSFs(13).
2. Moderate exercise
Moderate exercise to reduce the loss of fluid. If you involve in the extreme exercise, please remember to enough fluid to avoid dehydration.
3. Prevent vitamin overdose as they can cause the forming of kidney stones.
4. If you live in far North with water hardness, use water filter
5. If you are over weight or obese, lose weight
6. Reduced consumption of grapefruit juice cola drinks.
Study showed that grapefruit juice and cola drinks significantly (p=0.021) increased urinary excretion of citrate (25.8+/-9.3 vs 18.7+/-6.2 mg/h), calcium (6.7+/-4.3 vs 3.3+/-2.3 mg/h, p=0.015) and magnesium (2.9+/-1.5 vs 1.0+/-0.7 mg/h, p=0.003) and in the prevention of calcium renal stones a reduced sugar content is desirable to avoid the increase of urinary calcium due to the effect of sugar supplementation(14).
7. Drink more juices (organic)
Researchers at the University of Bonn, in the study of influence of grapefruit-, orange- and apple-juice consumption on urinary variables and risk of crystallization, indicated that due to an increased pH value and an increased citric acid excretion after consumption of each juice, the RSCaOx decreased statistically significantly (P<0.05) for grapefruit juice, but not significantly for orange and apple juice. The BONN risk index yielded a distinct decrease in the crystallization risk. We showed that both grapefruit juice and apple juice reduce the risk of CaOx stone formation at a magnitude comparable with the effects obtained from orange juice(15).
7. Increased intake of fruits with high in magnesium and potassium
Grapefruit juice significantly (p=0.021) increased urinary excretion of citrate (25.8+/-9.3 vs 18.7+/-6.2 mg/h), calcium (6.7+/-4.3 vs 3.3+/-2.3 mg/h, p=0.015) and magnesium (2.9+/-1.5 vs 1.0+/-0.7 mg/h, p=0.003). Citrus fruit juices could represent a natural alternative to potassium citrate in the management of nephrolithiasis(16).
8. Reduce intake of foods containing high amount of oxalate such as spinach, rhubarb, nuts, wheat bran, etc.
9. Others
According to the study of Dietary Factors and Risk of Kidney Stone: A Case-Control Study in Southern China, researchers at the Nanfang Hospital, Guangzhou, indicated that positive associations of kidney stones include consumption of grains (odds ratio [OR] = 2.08; 95% confidence interval [CI] = 1.08, 4.02) and bean products (OR = 3.50; 95% CI = 1.61, 7.59) in women. The variable "fluid drinking" showed a significant protective effect against kidney stones in men (OR = 0.57; 95% CI = 0.36, 0.88). Consuming leafy vegetables more than 3 times per day was positively associated with stones in both men and women (OR = 2.02; 95% CI = 1.04, 3.91 and OR = 3.86; 95% CI = 1.48, 10.04, respectively)(17).
V. Treatment
A. In conventional medicine perspective
Most kidney with diameter less than 5 mm (0.20 in) may pass through the urinary tract through urination within days of the onset of symptoms
A.1. Medications
The aims of medication is to manage pain or assist the speed up the spontaneous passage of ureteral calculi
1. Analgesia
Medication used to relieve pain.
2. Expulsion therapy
a. In the study to evaluate the efficacy of alfuzosin as medical expulsive therapy for distal ureteral stone passage od a total of 76 patients with a distal ureteral calculus, showed that the overall spontaneous stone passage rate was 75%, including 77.1% for placebo and 73.5% for alfuzosin (p = 0.83). Mean +/- SD time needed to pass the stone was 8.54 +/- 6.99 days for placebo vs 5.19 +/- 4.82 days for alfuzosin. (p = 0.003). There was no difference in the size or volume of stones that passed spontaneously between the placebo and alfuzosin arms, as measured on baseline computerized tomography (4.08 +/- 1.17 and 3.83 +/- 0.95 mm, p = 0.46) and by a digital caliper after stone expulsion (3.86 +/- 1.76 and 3.91 +/- 1.06 mm, respectively, p = 0.57). When comparing the improvement from the baseline pain score, the alfuzosin arm experienced a greater decrease in pain score in the days after the initial emergency department visit to the date of stone passage (p = 0.0005)(18).
A.2. Non invasive treatment and surgery
Extracorporeal shockwave lithotripsy does not require anaesthesia and requires little analgesia so that treatment can be given on an outpatient basis, and there is no wound to heal. Only a small puncture site is needed for percutaneous endoscopic lithotomy, and with the advent of prophylactic antibiotics there are few complications. Of renal stones, about 85% can now be successfully treated by extracorporeal lithotripsy alone, and almost all of the stones too large or hard for lithotripsy can be treated endoscopically, with ultrasonic or electrohydraulic probes being used to fragment the stone(19).
A.3. Recurrent treatments
2.1. Recurrent cystine renal stones
In the report of using ureterorenoscopy (URS) for the treatment of recurrent renal cystine stones. From 2003 to 2007, 10 patients (4 males and 6 females) with one or multiple recurrent renal cystine stones underwent URS. Overall, 21 procedures have been performed. Mean maximum diameter of stones was 11.2 mm (range 5-30 mm). Either 8-9.5 F semirigid or 7.9 F flexible ureteroscopes were used. In 6 cases, stones were removed using a basket; in 9 procedures laser lithotripsy with flexible scope was performed; in 6 cases renal calculi were pulled down in the ureter using flexible instrument and then shattered with laser introduced by semirigid instrument. Stone-free status was defined as the absence of any residual fragment. A complete stone clearance was obtained in 15 out of 21 procedures (71%). In 5 cases (24%) significant residual fragments occurred; in the remaining case (5%) URS was ineffective. In 5 out of these unsuccessful procedures, stone clearance was obtained with auxiliary treatments. The last patient has not been treated yet(20).
2.2. In general
Patients with kidney stones are highly motivated to prevent recurrence and were more amenable to fluid intake change than to another dietary or pharmaceutical intervention. Barriers preventing fluid intake success aligned into 3 progressive stages.
a. Stage 1 barriers included not knowing the benefits of fluid or not remembering to drink.
b. Stage 2 barriers included disliking the taste of water, lack of thirst and lack of availability.
c. Stage 3 barriers included the need to void frequently and related workplace disruptions.
Tailoring fluid intake counseling based on patient stage may improve fluid intake behavior(21).
B. In herbal medicine perspective
1. Asparagus racemosus Willd
In the study of the ethanolic extract of Asparagus racemosus Willd. for its inhibitory potential on lithiasis (stone formation), induced by oral administration of 0.75% ethylene glycolated water to adult male albino Wistar rats for 28 days, showed that the histopathological findings also showed signs of improvement after treatment with the extract. All these observations provided the basis for the conclusion that this plant extract inhibits stone formation induced by ethylene glycol treatment(22).
2. Goldenrod
Investigations in molecular pharmacology could show new mechanisms responsible for the biological effect of natural product from goldenrod extracts. The use of such herbal preparations with a rather complex action spectrum (anti-inflammatory, antimicrobial, diuretic, antispasmodic, analgesic) is especially recommended for treatment of infections and inflammations, to prevent formation of kidney stones and to help remove urinary gravel. This therapy is safe at a reasonable price and does not show drug-related side-effects, according to the study of the Institut für Pharmazie der Freien Universität Berlin, Berlin(23).
3. Other herbs
In the study of the effects of seven plants with suspected application to prevent and treat stone kidney formation (Verbena officinalis, Lithospermum officinale, Taraxacum officinale, Equisetum arvense, Arctostaphylos uva-ursi, Arctium lappa and Silene saxifraga) in female Wistar rats, showed that beneficial effects caused by these herb infusions on urolithiasis can be attributed to some disinfectant action, and tentatively to the presence of saponins. Specifically, some solvent action can be postulated with respect to uric stones or heterogeneous uric nucleus, due to the basifying capacity of some herb infusions. Nevertheless, for all the mentioned beneficial effects, more effective and equally innocuous substances are well known(24).
4. Etc.
C. In the traditional Chinese medicine perspective
C.1. According to the article of Chinese medicine Hospital for Chronic and Difficult diseases(25), traditional Chinese medicine defined kidney stones is a condition caused by
1. Qi stagnation
a. The aim of the herbal treatment is to Promotethe circulation of qi, inducing diuresis, relieving strangury and removing the stones.
b. Herbal formula: Modified Pyrrosia Decoction
Lysimachia, Pyrrosia leaf, Plantago seed, Cluster mallow fruit, Oriental water plantain rhizome, Citron fruit, Vaccaria seed, Radish seed and Rhubarb.
2. Damp-Heat Pattern
a. The aim of the herbal formula is to clear heat and dampness, relieve strangury and remove the stones.
b. Herbal formula: Modified Eight Health Restoring Powder
Lysimachia, Prostrate knotweed, Chinese pink herb, Talc, Phellodendron bark, Capejasmine fruit and Plantago seed , Rhubarb and Licorice root tip
3. Kidney deficiency
a. The aim of the herb used to treat kidney stones as a result of kidney deficiency is to tonify qi, reinforce the kidney, relieve stranguria and remove the stones.
b. Herbal formula: Modified Kidney-Reinforcing Decoction
Prepared rehmannia root, Wolfberry fruit, Dogwood fruit, Achyranthes root, Bighead atractylodes. Rhizome eucommia bark, Cinnamon bark, Pilose asiabell root, Lysimachia and Climbing fern spore
C.2. Chinese herbal formula Wu Ling San (Poria, Rhizoma Alismatis, Polyporus, Cortex Cinnamomi, Rhizoma Atractylodis Macrocephalae (stir-baked))
In the study to determine the effects of a traditional Chinese herbal formula, Wulingsan (WLS), on renal stone prevention using an ethylene glycol-induced nephrocalcinosis rat model. Forty-one male Sprague-Dawley (SD) rats were divided into four groups. Group 1 (n=8) was the normal control; group 2 (n=11) served as the placebo group, and received a gastric gavage of starch and 0.75% ethylene glycol (EG) as a stone inducer; group 3 received EG and a low dose of WLS (375 mg/kg); and group 4 received EG and a high dose of WLS (1,125 mg/kg), found that the rats of placebo group gained the least significant body weight; in contrast, the rats of WLS-fed groups could effectively reverse it. The placebo group exhibited lower levels of free calcium (p=0.059) and significantly lower serum phosphorus (p=0.015) in urine than WLS-fed rats. Histological findings of kidneys revealed tubular destruction, damage and inflammatory reactions in the EG-water rats. The crystal deposit scores dropped significantly in the WLS groups, from 1.40 to 0.46 in the low-dose group and from 1.40 to 0.45 in the high-dose group. Overall, WLS effectively inhibited the deposition of calcium oxalate (CaOx) crystal and lowered the incidence of stones in rats (p=0.035). In conclusion, WLS significantly reduced the severity of calcium oxalate crystal deposits in rat kidneys, indicating that Wulingsan may be an effective antilithic herbal formula(26).
Natural Remedies for Dementia Memory Loss Reversal
Guarantee to Stop Progression and Reverse Memory Loss in Alzheimer and Dementia with step by step instructions through Scientific Studies within 2 Months or your Money back
Super foods Library, Eat Yourself Healthy With The Best of the Best Nature Has to Offer
For over 100 healthy recipes, http://diseases-researches.blogspot.ca/p/blog-page_17.html
Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/12649987
(1a) http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/stones_in_the_urinary_tract/stones_in_the_urinary_tract.html?qt=&sc=&alt=
(2) http://www.ncbi.nlm.nih.gov/pubmed/22218117
(3) http://www.ncbi.nlm.nih.gov/pubmed/20420802
(3a) http://www.ncbi.nlm.nih.gov/pubmed/22341269
(3b) http://www.ncbi.nlm.nih.gov/pubmed/15253722
(3c) http://www.ncbi.nlm.nih.gov/pubmed/6269684
(3d) http://www.ncbi.nlm.nih.gov/pubmed/10203369
(4) http://www.ncbi.nlm.nih.gov/pubmed/15865513
(5) http://www.ncbi.nlm.nih.gov/pubmed/9335385
(6) http://www.ncbi.nlm.nih.gov/pubmed/15493118
(7) http://www.ncbi.nlm.nih.gov/pubmed/17096158
(8) http://www.ncbi.nlm.nih.gov/pubmed/12649987
(9) http://www.ncbi.nlm.nih.gov/pubmed/22461670
(10) http://www.ncbi.nlm.nih.gov/pubmed/9873217
(11) http://www.ncbi.nlm.nih.gov/pubmed/22498635
(12) http://www.ncbi.nlm.nih.gov/pubmed/7671093
(13) http://www.ncbi.nlm.nih.gov/pubmed/21825103
(14) http://www.ncbi.nlm.nih.gov/pubmed/12408462
(15) http://www.ncbi.nlm.nih.gov/pubmed/12908889
(16) http://www.ncbi.nlm.nih.gov/pubmed/12408462
(17) http://www.ncbi.nlm.nih.gov/pubmed/22658934
(18) http://www.ncbi.nlm.nih.gov/pubmed/18423747
(19) http://www.ncbi.nlm.nih.gov/pubmed/8274898
(20) http://www.ncbi.nlm.nih.gov/pubmed/21193905
(21) http://www.ncbi.nlm.nih.gov/pubmed/22341296
(22) http://www.ncbi.nlm.nih.gov/pubmed?term=asparagus%20root%20and%20kidney%20stones
(23) http://www.ncbi.nlm.nih.gov/pubmed/15638071
(24) http://www.ncbi.nlm.nih.gov/pubmed/7860196
(25) http://www.tcmtreatment.com/images/diseases/urinary-calculus.htm
(26) http://www.ncbi.nlm.nih.gov/pubmed/18040675
Saturday, October 13, 2012
Trigeminal neuralgia
Trigeminal neuralgia is defined as a condition of episodes of intense facial pain as a result of the affect of trigeminal nerve, containing 3 branches. The first (upper) branch includes the eye, eyebrow, and forehead. The second (middle) branch corresponds to the upper lip, upper teeth, upper gum, cheek, lower eyelid, and side of the nose. The third (lower) branch involves the lower lip, lower teeth, lower gum, and one side of the tongue. It also includes a narrow area that extends from the lower jaw in front of the ear to the side of the head(1). The pain is nearly always unilateral, and it may occur repeatedly
throughout the day(2).
I. Signs and symptoms
The abrupt onset of short pains in the face or in a part of the face, including
1. Stabbing
2. Lightning
3. Electric shocks(3).
4. Autonomic symptoms can occur in association with the facial pain of trigeminal neuralgia (TN).the most common autonomic symptoms were conjunctival injection, ptosis, and excessive tearing (4).
5. In the study to evaluate a total of 30 patients with TN and chronic facial pain (group A, 25 women and 5 men; mean age, 64.2±3.2 years) and 30 with atypical facial pain (group B, 26 women and 4 men; mean age, 64.8±1.9 years, researchers at the Lithuanian University of Health Sciences, showed that patients with TN and chronic facial pain had a significantly higher level of pain perception, and they presented the higher level for anxiety and depression than those with atypical facial pain(5).
6. Etc.
II. Causes and Risk factors
A. Causes
1. Neurovascular compression (NC)
Neurovascular compression (NC) seems to have been confirmed as the major cause of classical trigeminal neuralgia (TN)(6).
2. Tumor in the brain
There are a reprot of three cases of contralateral trigeminal neuralgia as a false localizing sign in intracranial tumors. In all cases, tumors were large and firm. The tumor was supratentorial in two cases. In one case, a cortically mediated mechanism may have caused the neuralgia, whereas in the remaining two cases distortion and displacement of the brain stem and compression of the contralateral Meckel's cave would explain the trigeminal nerve signs(7).
3. Multiple sclerosis
Multiple Sclerosis is an inflammation of central nervous system disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are deteriorated, leading to impair of proper conduction of nerve impulse. In a multicentre controlled study of 130 patients with MS: 50 patients with TN, 30 patients with trigeminal sensory disturbances other than TN (ongoing pain, dysaesthesia, or hypoesthesia), and 50 control patients, found that the most likely cause of MS-related TN is a pontine plaque damaging the primary afferents. Nevertheless, in some patients a neurovascular contact may act as a concurring mechanism. The other sensory disturbances, including ongoing pain and dysaesthesia, may arise from damage to the second-order neurons in the spinal trigeminal complex(8).
4. Shingles
Shingles also known as herpes zoster or zona is defined as a viral disease with condition of a painful, blistering skin rash on one side of the body of that can continue to be painful even after the rash have long disappeared(1), as a result of varicella-zoster viral causes of a nerve and skin inflammation. There is a report of a case of reactivation of herpes zoster along the trigeminal nerve with intractable pain after facial trauma(9).
5. Etc.
B. Risk factors
1. Age
If you are 50 or older, you are at increased risk to develop Trigeminal neuralgia.
2. Sex
If you are female, your risk of develop TN are increased.
3. Familial risks
In the study of familial risks for siblings who were hospitalised for nerve, nerve root and plexus disorders in Sweden, showed that 29,686 patients, 43% men and 57% women, were diagnosed at a mean age of 37.5 years. 191 siblings were hospitalised for these disorders, giving an overall SIR of 2.59 (95% CI 1.58 to 4.22), with no sex difference(10).
3. Certain conditions
a. Hypertension
Increased risk of trigeminal neuralgia after hypertension. In the hypertension group, 121 patients developed TN during follow-up, while, in the nonhypertension group, 167 subjects developed TN. The crude hazard ratio for the hypertension group was 1.52 (95% confidence interval [CI] 1.20-1.92; p = 0.0005), while, after adjustment for demographic characteristics and medical comorbidities, the adjusted hazard ratio was 1.51 (95% CI 1.19-1.90; p = 0.0006)(11).
b. Multiple sclerosis
Multiple sclerosis are associated with the increased risk of Trigeminal neuralgia.
c. Etc.
III. Diagnosis and Misdiagosis
A. Misdiagosis
1. Acute dental pain
Pre-trigeminal and atypical neuralgias are amongst the possible differential diagnoses of acute dental pain. * In a patient with nonodontogenic pain, simultaneous dental pain in the same area could be overlooked. * Dentists should consider a nonodontogenic origin as a possible explanation for burning, lancinating or atypical pain. In such cases, an appropriate medical specialist should be consulted, according to Dr. Sanner F.(12)
2. Paroxysmal orofacial pains
Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton's neuralgia, cluster headache and paroxysmal hemicrania, according to Dr. de Bont LG. at the Universitair Medisch Centrum, Groningen(13).
3. Trigeminal neuralgia and other facial pain
Attacks of facial pain are often triggered by cutaneous stimuli to the face or the oral cavity, which may be such minor activities as talking, chewing, brushing the teeth, or even wind blowing on the face. As a result, facial hygiene as well as a good diet may be neglected. Although 1% of the patients may eventually develop the disorder bilaterally, pain does not cross the midline during any single episode. The clinical course is characterized by exacerbations and remissions, but as the disorder progresses, remissions become shorter and exacerbations more severe. If the trigeminal neuralgia may be considered as a nerve irritation, like the glossopharyngeal neuralgia and the nasociliary neuralgia, nerve lesion may elicit neurogenic or neuropathic pain, characterized by chronic burning pain; post-zoster pain, iatrogenic and posttraumatic pain illustrate this condition. Cluster headache (Horton neuralgia), Sluder's neuralgia and auriculotemporal neuralgia may be related to a dysfunction of the autonomous nervous system(14).
4. Leprosy
There is a report of healthy without any overt features suggestive of infection patient who had migrated to Australia from India 24 years previously, but a review of the literature revealed that the trigeminal nerve is frequently involved in leprosy, usually associated with sensory loss rather than neuropathic pain(15).
5 Etc.
B. Diagnosis
The diagnosis is typically determined clinically, although imaging studies or referral for specialized testing may be necessary to rule out other diseases. Accurate and prompt diagnosis is important because the pain of trigeminal neuralgia can be severe(16).
According to International Headache Society diagnostic criteria for trigeminal neuralgia, Trigeminal neuralgia is diagnosed depending to
Classical
Risk of stroke increases after Trigeminal neuralgia, according to the study of population-based follow-up study to investigate whether the occurrence of TN is associated with a higher risk of developing stroke(18).
V. Treatment
V.1. Treatment in conventional medicine perspective
A. Medication
1. Carbamazepine
Carbamazepine is currently the drug of first choice in the treatment of trigeminal neuralgia. However, it is reported as efficacious in only 70-80% of patients, and can be associated with adverse effects such as drowsiness, confusion, nausea, ataxia, nystagmus and hypersensitivity, which may necessitate discontinuation of medication(19).
2. Topiramate
In the trials comparing topiramate with carbamazepine are all poor in methodological quality. A meta-analysis of these studies showed that the overall effectiveness and tolerability of topiramate did not seem to differ from carbamazepine in the treatment of classical trigeminal neuralgia. However, the meta-analysis yielded a favourable effect of topiramate compared with carbamazepine after a treatment duration of 2 months. Results were limited due to the poor methodological quality and the geographic localization of the randomized controlled trials identified. Therefore, large, international, well conducted, randomized controlled trials are needed to further assess the relative efficacy and tolerability of topiramate and carbamazepine in this indication(20)
Side effects include Loss of appetite, dizziness, and tingling sensations, etc.
3. Lamotrigine
In the study of 21e patients with TN administered with LTG in comparison to CBZ. in the clinical trials comprised two phases of 40 days each, with an intervening three-day washout period, showed that oth on VAS and VRS assessments, in terms of proportion of patients, CBZ benefitted 90.5% (19/21) of the patients with pain relief (p < 0.05), in contrast to 62% (13/21) from LTG. On VAS assessment, of the 13 patients who gained pain relief from LTG and 19 from CBZ, 77% (10/13) obtained a "complete" degree of pain relief from LTG, as compared with 21% (4/19) from CBZ. On VRS assessment, with LTG, 84% (11/13) of the patients accomplished "much better" degree of pain relief, as compared with 26% (5/19) with CBZ. On LTG, 67% (14/21) of patients endured general pharmacological side effects, as compared with 57% (12/21) of patients on CBZ (p > 0.05). Meanwhile, LTG inflicted 14% (3/21) of the patients with haematological, hepatic and renal derangements, as compared with 48% (10/21) on CBZ(21).
Side effects include nausea, dizziness, headaches, coordination problems, etc.
4. Etc.
B. Surgical treatments
1. Peripheral neurectomies, a minimally invasive treatment for trigeminal neuralgia
In the study to investigate the efficacy of peripheral neurectomy as a surgical procedure in the treatment of trigeminal neuralgia and to evaluate the results obtained by this procedure and their recurrences in a period of three years followup, researchers at the Modern Dental Collage & Research Centre, showed that peripheral neurectomy is one of the oldest, minimal invasive forms of surgery, well tolerated by the patient and can be done under local anesthesia(22)
Others suggested that peripheral neurectomy is thus a safe and effective procedure for elderly patients, for those patients living in remote and rural places that cannot avail major neurosurgical facilities, and for those patients who are reluctant for major neurosurgical procedures(23).
According to the study by Dr. Freemont AJ, and DR. Millac P. Of 49 patients ultimately maintained pain-free by non-medical means, 26 underwent peripheral neurectomy. Twenty of these achieved excellent pain control in the longer term and 5 of the remaining 6 became more responsive to carbamazepine after operation. Seven patients required repeat neurectomies(24).
2. Trigeminal Root Compression of trigeminal nerve
In the study of the Efficacy and safety of root compression of trigeminal nerve for trigeminal neuralgia with out evidence of vascular compression, found that all patients were pain free after the procedure; there was a 27% relapse in a mean time of 10 months, but 83% of these patients were adequately controled by medical treatment, and only 17% needed a complementary procedure for pain relief. Also we found that 63% of the patients complained of a partial loss of facial sensitivity, but only one patient presented with a corneal ulcer. There were a 6.7% rate of significant complications. We concluded that Trigeminal Root Compression is a safe and effective option for patients with primary trigeminal neuralgia without vascular compression(25).
TN is frequently associated with nerve root entry zone demyelination in MS and patients with nerve root vascular compression. The characteristics of the TN and response to PSR are similar in both groups. Persistent vascular compression increases the risk of recurrent TN after PSR(26).
3. Microvascular decompression (MVD)
In the study to evaluate the long-term efficacy of microvascular decompression (MVD) and to identify the factors affecting outcome in patients treated for primary trigeminal neuralgia (TN), researchers at the
Hôpital Neurologique Pierre Wertheimer, University of Lyon, found that Pure MVD can offer patients affected by a primary TN a 73.38% probability of long-term (15 years) cure of neuralgia. The presence of a clear-cut and marked vascular compression at surgery (and possibly-although not yet reliably--on preoperative magnetic resonance imaging) is the guarantee of a higher than 90% success rate(27).
In Microvascular decompression (MVD), the Complete pain relief (off medication) achieved in 71% of patients at 10 years. Overall 84% of responders to questionnaires expressed satisfaction with the operative outcome, the mean duration of TGN was 80 months and mean post-operative follow-up of 7 years. No mortality reported in this series(28).
4. Gamma Knife surgery
In the comparison of data across previous reports hampered by differences in treatment protocols, lengths of follow-up, and outcome criteria, researchers at the Sint Elisabeth Hospital, Tilburg found that
in the idiopathic TN group, rates of adequate pain relief, defined as BNI Pain Scores I-IIIB, were 75%, 60%, and 58% at 1, 3, and 5 years, respectively. In the multiple sclerosis (MS)-related TN group the rates of adequate pain relief were 56%, 30%, and 20% at 1, 3, and 5 years, respectively. Repeated GKS was as successful as the first. An analysis of our treatment strategy of repeated GKS showed rates of adequate pain relief of 75% at 5 years in the idiopathic TN and 46% in the MS-related TN group. Somewhat bothersome numbness was reported by 6% of patients after the first treatment and by 24% after repeated GKS. Very bothersome numbness was reported in 0.5% after the first GKS and in 2% after the second treatment(29).
During the radiosurgical procedure, 19 patients (2%) suffered anxiety or syncopal episodes, and 2 patients suffered acute coronary events. Treatments were incompletely administered in 12 patients (1.2%). Severe pain was a delayed complication: 8 patients suffered unexpected headaches, and 9 patients developed severe facial pain. New motor deficits developed in 11 patients, including edema-induced ataxia in 4 and one case of facial weakness after treatment of a vestibular schwannoma. Four patients required shunt placement for symptomatic hydrocephalus, and 16 patients suffered delayed seizures(30).
5. Radiofrequency
V.2. Treatment in herbal medicine perspective
The aim of herbal treatment is to relieve pain or discomfort and support the function of the peripheral nerves.
1. Corydalis yanhusuo
In the study to evaluate the analgesic effect of Corydalis yanhusuo on trigeminal neuropathic pain.in a rat mode suggested that the analgesic effect of Yanhusuo involves the participation of CB1 receptors, suggesting that Yanhusuo may offer a useful therapeutic approach for trigeminal neuropathic pain(41).
2. Uyakujunkisan (UJS)
There is a report of a 65-year-old female who developed right-sided trigeminal neuralgia that was partially responsive to carbamazepine (CZ). The pain gradually increased in intensity and at 72 years of age she presented for herbal medicine therapy. Cranial MRI demonstrated vascular compression of the right trigeminal nerve at the cerebellopontine angle by the anterior inferior cerebellar artery. Although microvascular decompression was considered, UJS was prescribed after informed consent. After 3 weeks of treatment with UJS, dramatic improvement of symptoms permitted a decrease in CZ dose(42).
3. Saiko-Keishi-To (TJ-10)
In the study to verify the effectiveness of TJ-10, Wistar rats with chronic neuralgia of the mandibular nerve were prepared and TJ-10 was administered to them for 4 weeks following the manifestation of pain in the mandibular region. The result reveals that the rise in the pain threshold in the mandibular region is more significant in the rats administered TJ-10 than in those in the control group. However, in the tail flick test, no significant change was observed in the pain threshold. These findings suggest that TJ-10 is effective for controlling the manifestation of pain in ligatured nerves, by local effect, not by general analgesic effect(43).
4. Herbal formula containing Ganoderma lucidum, WTMCGEPP
Administration of hot water extracts of a herbal formula containing Ganoderma lucidum, WTMCGEPP (Wisteria floribunda 0.38, Trapa natans 0.38, Miristica agrans 0.38, Coix lachryma-jobi 0.75, cultivated Ganoderma lucidum 0.75, Elfuinga applanata 0.38, tissue cultured Panax ginseng 0.3, and Punica granatum 0.38: numerals designate dry weight gram/dose), decreased herpes zoster pain for five Japanese patients suffering from shingles. Pain relief started within a few days of intake and was almost complete within 10 days. Two acute herpes zoster with manifestations including trigeminal nerve ophthalmia (both 74 years old), lower body zoster (70 years old), herpes zoster oticus (17 years old), and leg herpes (28 years old), responded quickly to treatment and no patient developed post-herpetic neuralgia (PHN) after more than one year of follow-up(44)
5. Etc.
V.3. Treatment in traditional Chinese perspective
1. Siwei Shaoyao Decoction
Siwei Shaoyao Decoction possesses a marked effect on the alleviation of trigeminal neuralgia in rats caused by penicillin G potassium injection. As shown from the hot-plate test, it also has an obvious analgesic effect on mice. To some extent, the decoction has a significant anti-inflammatory effect on the acute edema in hind paws of rats and the effect is believed to be related to the reduction of capillary permeability, according to the study by Guiyang College of Traditional Chinese Medicine(45)
2. Sanchaning
In an experimental study and the comparision of the effect of Sanchaning with that of distilled water as well as carbamazepine, a common Western medicine for curing PTN, Sanchaning differed significantly from distilled water in treating PTN (P < 0.01), but slightly differed from that of carbamazepine (P < 0.05). The sequential trial has identified that Sanchaning could be used effectively to inhibit PTN and has the same effect as carbamazepine. But further study should be carried out to investigate the mechanism of its function in relieving PTN(46).
3. Yokukansan (Yi-Gan San)
According to the report of Juntendo University School of Medicine, the efficacy of Yokukansan in patients with neuropathic pain, including acute herpetic pain, postherpetic neuralgia, central poststroke pain, post-traumatic spinal cord injury pain, thalamic syndrome, complex regional pain syndrome and symptomatic trigeminal neuralgia. Yokukansan was more effective compared with traditional medicines, such as tricyclic antidepressants, carbamazepine, gabapentin, and opioids etc., which are recommended to treat neuropathic pain(47).
4. Etc.
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Sources
(1) http://www.neurosurgery.ufl.edu/clinical-specialties/images/trigeminal_neuralgia_brochure_for_web.pdf
(2) http://www.ncbi.nlm.nih.gov/pubmed/18540495
(3) http://www.ncbi.nlm.nih.gov/pubmed/9139410
(4) http://www.ncbi.nlm.nih.gov/pubmed/21568653
(5) http://www.ncbi.nlm.nih.gov/pubmed/22112988
(6) http://www.ncbi.nlm.nih.gov/pubmed/16472332
(7) http://www.ncbi.nlm.nih.gov/pubmed/3808248
(8) http://www.ncbi.nlm.nih.gov/pubmed/19171430
(9) http://www.ncbi.nlm.nih.gov/pubmed/21686763
(10) http://www.ncbi.nlm.nih.gov/pubmed/17183020
(11) http://www.ncbi.nlm.nih.gov/pubmed/21998318
(12) http://www.ncbi.nlm.nih.gov/pubmed/20078705
(13) http://www.ncbi.nlm.nih.gov/pubmed/17147031
(14) http://www.ncbi.nlm.nih.gov/pubmed/9139410
(15) http://www.ncbi.nlm.nih.gov/pubmed/22558614
(16) http://www.ncbi.nlm.nih.gov/pubmed/18540495
(17) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033033/table/t1-jpr-3-249/
(18) http://www.ncbi.nlm.nih.gov/pubmed/21511953
(19) http://www.ncbi.nlm.nih.gov/pubmed/21936587
(20) http://www.ncbi.nlm.nih.gov/pubmed/21936587
(21) http://www.ncbi.nlm.nih.gov/pubmed/21621166
(22) http://www.ncbi.nlm.nih.gov/pubmed/22865967
(23) http://www.ncbi.nlm.nih.gov/pubmed/22865967
(24) http://www.ncbi.nlm.nih.gov/pubmed/7267511
(25) http://www.ncbi.nlm.nih.gov/pubmed/22889619
(26) http://www.ncbi.nlm.nih.gov/pubmed/22130049
(27) http://www.ncbi.nlm.nih.gov/pubmed/18077952
(28) http://www.ncbi.nlm.nih.gov/pubmed/20158348
(29) http://www.ncbi.nlm.nih.gov/pubmed/21121797
(30) http://www.ncbi.nlm.nih.gov/pubmed/19123881
(31) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033033/
(32) http://www.ncbi.nlm.nih.gov/pubmed/22583706
(33) http://www.ncbi.nlm.nih.gov/pubmed/19298979
(34) http://www.ncbi.nlm.nih.gov/pubmed/22545013
(35) http://www.ncbi.nlm.nih.gov/pubmed/9733301
(36) http://www.ncbi.nlm.nih.gov/pubmed/21866065
(37) http://www.ncbi.nlm.nih.gov/pubmed/8727810
(38) http://www.ncbi.nlm.nih.gov/pubmed/22392016
(39) http://www.ncbi.nlm.nih.gov/pubmed/21901707
(40) http://www.ncbi.nlm.nih.gov/pubmed/22840414
(41) http://www.ncbi.nlm.nih.gov/pubmed/20855279
(42) http://www.ncbi.nlm.nih.gov/pubmed/18694452
(43) http://www.ncbi.nlm.nih.gov/pubmed/11424461
(44) http://www.ncbi.nlm.nih.gov/pubmed/16173526
(45) http://www.ncbi.nlm.nih.gov/pubmed/9208559
(46) http://www.ncbi.nlm.nih.gov/pubmed/7640504
(47) http://www.ncbi.nlm.nih.gov/pubmed/19860227
I. Signs and symptoms
The abrupt onset of short pains in the face or in a part of the face, including
1. Stabbing
2. Lightning
3. Electric shocks(3).
4. Autonomic symptoms can occur in association with the facial pain of trigeminal neuralgia (TN).the most common autonomic symptoms were conjunctival injection, ptosis, and excessive tearing (4).
5. In the study to evaluate a total of 30 patients with TN and chronic facial pain (group A, 25 women and 5 men; mean age, 64.2±3.2 years) and 30 with atypical facial pain (group B, 26 women and 4 men; mean age, 64.8±1.9 years, researchers at the Lithuanian University of Health Sciences, showed that patients with TN and chronic facial pain had a significantly higher level of pain perception, and they presented the higher level for anxiety and depression than those with atypical facial pain(5).
6. Etc.
II. Causes and Risk factors
A. Causes
1. Neurovascular compression (NC)
Neurovascular compression (NC) seems to have been confirmed as the major cause of classical trigeminal neuralgia (TN)(6).
2. Tumor in the brain
There are a reprot of three cases of contralateral trigeminal neuralgia as a false localizing sign in intracranial tumors. In all cases, tumors were large and firm. The tumor was supratentorial in two cases. In one case, a cortically mediated mechanism may have caused the neuralgia, whereas in the remaining two cases distortion and displacement of the brain stem and compression of the contralateral Meckel's cave would explain the trigeminal nerve signs(7).
3. Multiple sclerosis
Multiple Sclerosis is an inflammation of central nervous system disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are deteriorated, leading to impair of proper conduction of nerve impulse. In a multicentre controlled study of 130 patients with MS: 50 patients with TN, 30 patients with trigeminal sensory disturbances other than TN (ongoing pain, dysaesthesia, or hypoesthesia), and 50 control patients, found that the most likely cause of MS-related TN is a pontine plaque damaging the primary afferents. Nevertheless, in some patients a neurovascular contact may act as a concurring mechanism. The other sensory disturbances, including ongoing pain and dysaesthesia, may arise from damage to the second-order neurons in the spinal trigeminal complex(8).
4. Shingles
Shingles also known as herpes zoster or zona is defined as a viral disease with condition of a painful, blistering skin rash on one side of the body of that can continue to be painful even after the rash have long disappeared(1), as a result of varicella-zoster viral causes of a nerve and skin inflammation. There is a report of a case of reactivation of herpes zoster along the trigeminal nerve with intractable pain after facial trauma(9).
5. Etc.
B. Risk factors
1. Age
If you are 50 or older, you are at increased risk to develop Trigeminal neuralgia.
2. Sex
If you are female, your risk of develop TN are increased.
3. Familial risks
In the study of familial risks for siblings who were hospitalised for nerve, nerve root and plexus disorders in Sweden, showed that 29,686 patients, 43% men and 57% women, were diagnosed at a mean age of 37.5 years. 191 siblings were hospitalised for these disorders, giving an overall SIR of 2.59 (95% CI 1.58 to 4.22), with no sex difference(10).
3. Certain conditions
a. Hypertension
Increased risk of trigeminal neuralgia after hypertension. In the hypertension group, 121 patients developed TN during follow-up, while, in the nonhypertension group, 167 subjects developed TN. The crude hazard ratio for the hypertension group was 1.52 (95% confidence interval [CI] 1.20-1.92; p = 0.0005), while, after adjustment for demographic characteristics and medical comorbidities, the adjusted hazard ratio was 1.51 (95% CI 1.19-1.90; p = 0.0006)(11).
b. Multiple sclerosis
Multiple sclerosis are associated with the increased risk of Trigeminal neuralgia.
c. Etc.
III. Diagnosis and Misdiagosis
A. Misdiagosis
1. Acute dental pain
Pre-trigeminal and atypical neuralgias are amongst the possible differential diagnoses of acute dental pain. * In a patient with nonodontogenic pain, simultaneous dental pain in the same area could be overlooked. * Dentists should consider a nonodontogenic origin as a possible explanation for burning, lancinating or atypical pain. In such cases, an appropriate medical specialist should be consulted, according to Dr. Sanner F.(12)
2. Paroxysmal orofacial pains
Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton's neuralgia, cluster headache and paroxysmal hemicrania, according to Dr. de Bont LG. at the Universitair Medisch Centrum, Groningen(13).
3. Trigeminal neuralgia and other facial pain
Attacks of facial pain are often triggered by cutaneous stimuli to the face or the oral cavity, which may be such minor activities as talking, chewing, brushing the teeth, or even wind blowing on the face. As a result, facial hygiene as well as a good diet may be neglected. Although 1% of the patients may eventually develop the disorder bilaterally, pain does not cross the midline during any single episode. The clinical course is characterized by exacerbations and remissions, but as the disorder progresses, remissions become shorter and exacerbations more severe. If the trigeminal neuralgia may be considered as a nerve irritation, like the glossopharyngeal neuralgia and the nasociliary neuralgia, nerve lesion may elicit neurogenic or neuropathic pain, characterized by chronic burning pain; post-zoster pain, iatrogenic and posttraumatic pain illustrate this condition. Cluster headache (Horton neuralgia), Sluder's neuralgia and auriculotemporal neuralgia may be related to a dysfunction of the autonomous nervous system(14).
4. Leprosy
There is a report of healthy without any overt features suggestive of infection patient who had migrated to Australia from India 24 years previously, but a review of the literature revealed that the trigeminal nerve is frequently involved in leprosy, usually associated with sensory loss rather than neuropathic pain(15).
5 Etc.
B. Diagnosis
The diagnosis is typically determined clinically, although imaging studies or referral for specialized testing may be necessary to rule out other diseases. Accurate and prompt diagnosis is important because the pain of trigeminal neuralgia can be severe(16).
According to International Headache Society diagnostic criteria for trigeminal neuralgia, Trigeminal neuralgia is diagnosed depending to
Classical
- Paroxysmal attacks of pain lasting from a fraction of a second to 2 min, affecting one or more divisions of the trigeminal nerve, and fulfilling criteria B and C
- Pain has at least one of the following characteristics:
- Intense, sharp, superficial, or stabbing
- Precipitated from trigger zones or by trigger factors
- Attacks are sterotyped in the individual patient
- There is no clinically evident neurologic deficit
- Not attributed to another disorder
- Paroxysmal attacks of pain lasting from a fraction of a second to 2 min, with or without persistence of aching between paroxysms, affecting one or more divisions of the trigeminal nerve, and fulfilling criteria B and C
- Pain has at least one of the following characteristics:
- Intense, sharp, superficial, or stabbing
- Precipitated from trigger zones or by trigger factors
- Attacks are sterotyped in the individual patient
- A causative lesion, other than vascular compression, has been demonstrated by special investigations and/or posterior fossa exploration(17)
MRI is particularly useful in planning the management of those conditions where surgical or medical intervention can result in improvement or resolution of symptoms and to exclude the symptomatic TN due to multiple sclerosis and tumors.
Risk of stroke increases after Trigeminal neuralgia, according to the study of population-based follow-up study to investigate whether the occurrence of TN is associated with a higher risk of developing stroke(18).
V. Treatment
V.1. Treatment in conventional medicine perspective
A. Medication
1. Carbamazepine
Carbamazepine is currently the drug of first choice in the treatment of trigeminal neuralgia. However, it is reported as efficacious in only 70-80% of patients, and can be associated with adverse effects such as drowsiness, confusion, nausea, ataxia, nystagmus and hypersensitivity, which may necessitate discontinuation of medication(19).
2. Topiramate
In the trials comparing topiramate with carbamazepine are all poor in methodological quality. A meta-analysis of these studies showed that the overall effectiveness and tolerability of topiramate did not seem to differ from carbamazepine in the treatment of classical trigeminal neuralgia. However, the meta-analysis yielded a favourable effect of topiramate compared with carbamazepine after a treatment duration of 2 months. Results were limited due to the poor methodological quality and the geographic localization of the randomized controlled trials identified. Therefore, large, international, well conducted, randomized controlled trials are needed to further assess the relative efficacy and tolerability of topiramate and carbamazepine in this indication(20)
Side effects include Loss of appetite, dizziness, and tingling sensations, etc.
3. Lamotrigine
In the study of 21e patients with TN administered with LTG in comparison to CBZ. in the clinical trials comprised two phases of 40 days each, with an intervening three-day washout period, showed that oth on VAS and VRS assessments, in terms of proportion of patients, CBZ benefitted 90.5% (19/21) of the patients with pain relief (p < 0.05), in contrast to 62% (13/21) from LTG. On VAS assessment, of the 13 patients who gained pain relief from LTG and 19 from CBZ, 77% (10/13) obtained a "complete" degree of pain relief from LTG, as compared with 21% (4/19) from CBZ. On VRS assessment, with LTG, 84% (11/13) of the patients accomplished "much better" degree of pain relief, as compared with 26% (5/19) with CBZ. On LTG, 67% (14/21) of patients endured general pharmacological side effects, as compared with 57% (12/21) of patients on CBZ (p > 0.05). Meanwhile, LTG inflicted 14% (3/21) of the patients with haematological, hepatic and renal derangements, as compared with 48% (10/21) on CBZ(21).
Side effects include nausea, dizziness, headaches, coordination problems, etc.
4. Etc.
B. Surgical treatments
1. Peripheral neurectomies, a minimally invasive treatment for trigeminal neuralgia
In the study to investigate the efficacy of peripheral neurectomy as a surgical procedure in the treatment of trigeminal neuralgia and to evaluate the results obtained by this procedure and their recurrences in a period of three years followup, researchers at the Modern Dental Collage & Research Centre, showed that peripheral neurectomy is one of the oldest, minimal invasive forms of surgery, well tolerated by the patient and can be done under local anesthesia(22)
Others suggested that peripheral neurectomy is thus a safe and effective procedure for elderly patients, for those patients living in remote and rural places that cannot avail major neurosurgical facilities, and for those patients who are reluctant for major neurosurgical procedures(23).
According to the study by Dr. Freemont AJ, and DR. Millac P. Of 49 patients ultimately maintained pain-free by non-medical means, 26 underwent peripheral neurectomy. Twenty of these achieved excellent pain control in the longer term and 5 of the remaining 6 became more responsive to carbamazepine after operation. Seven patients required repeat neurectomies(24).
2. Trigeminal Root Compression of trigeminal nerve
In the study of the Efficacy and safety of root compression of trigeminal nerve for trigeminal neuralgia with out evidence of vascular compression, found that all patients were pain free after the procedure; there was a 27% relapse in a mean time of 10 months, but 83% of these patients were adequately controled by medical treatment, and only 17% needed a complementary procedure for pain relief. Also we found that 63% of the patients complained of a partial loss of facial sensitivity, but only one patient presented with a corneal ulcer. There were a 6.7% rate of significant complications. We concluded that Trigeminal Root Compression is a safe and effective option for patients with primary trigeminal neuralgia without vascular compression(25).
TN is frequently associated with nerve root entry zone demyelination in MS and patients with nerve root vascular compression. The characteristics of the TN and response to PSR are similar in both groups. Persistent vascular compression increases the risk of recurrent TN after PSR(26).
3. Microvascular decompression (MVD)
In the study to evaluate the long-term efficacy of microvascular decompression (MVD) and to identify the factors affecting outcome in patients treated for primary trigeminal neuralgia (TN), researchers at the
Hôpital Neurologique Pierre Wertheimer, University of Lyon, found that Pure MVD can offer patients affected by a primary TN a 73.38% probability of long-term (15 years) cure of neuralgia. The presence of a clear-cut and marked vascular compression at surgery (and possibly-although not yet reliably--on preoperative magnetic resonance imaging) is the guarantee of a higher than 90% success rate(27).
In Microvascular decompression (MVD), the Complete pain relief (off medication) achieved in 71% of patients at 10 years. Overall 84% of responders to questionnaires expressed satisfaction with the operative outcome, the mean duration of TGN was 80 months and mean post-operative follow-up of 7 years. No mortality reported in this series(28).
4. Gamma Knife surgery
In the comparison of data across previous reports hampered by differences in treatment protocols, lengths of follow-up, and outcome criteria, researchers at the Sint Elisabeth Hospital, Tilburg found that
in the idiopathic TN group, rates of adequate pain relief, defined as BNI Pain Scores I-IIIB, were 75%, 60%, and 58% at 1, 3, and 5 years, respectively. In the multiple sclerosis (MS)-related TN group the rates of adequate pain relief were 56%, 30%, and 20% at 1, 3, and 5 years, respectively. Repeated GKS was as successful as the first. An analysis of our treatment strategy of repeated GKS showed rates of adequate pain relief of 75% at 5 years in the idiopathic TN and 46% in the MS-related TN group. Somewhat bothersome numbness was reported by 6% of patients after the first treatment and by 24% after repeated GKS. Very bothersome numbness was reported in 0.5% after the first GKS and in 2% after the second treatment(29).
During the radiosurgical procedure, 19 patients (2%) suffered anxiety or syncopal episodes, and 2 patients suffered acute coronary events. Treatments were incompletely administered in 12 patients (1.2%). Severe pain was a delayed complication: 8 patients suffered unexpected headaches, and 9 patients developed severe facial pain. New motor deficits developed in 11 patients, including edema-induced ataxia in 4 and one case of facial weakness after treatment of a vestibular schwannoma. Four patients required shunt placement for symptomatic hydrocephalus, and 16 patients suffered delayed seizures(30).
5. Radiofrequency
Only Patients with a good to excellent pain relief
with a diagnostic trigeminal ganglion block and if the pain relief is of a
short duration may be suitable candidates
for percutaneous RF rhizotomy. It is performed by destruction of the trigeminal
ganglion or roots using RF. RF is the most common percutaneous procedure used to treat TN, especially in elderly patients(31).
According to the study of an analysis of 16 346 treated nodules in 13 283 patients, between January 1999 and November 2010. Five patients (0.038%) died: two
from intraperitoneal hemorrhage, and one each from hemothorax, severe
acute pancreatitis and perforation of the colon. In 16 346 treated
nodules, 579 complications
(3.54%) were observed, including 78 hemorrhages (0.477%), 276 hepatic
injuries (1.69%), 113 extrahepatic organ injuries (0.691%) and 27 tumor
progressions (0.17%). The centers that treated a large number of nodules
and performed RFA modifications, such as use of artificial ascites,
artificial pleural effusion and bile duct cooling, had low complication
rates(32).
6. Balloon compression
In the retrospective study of 121 patients treated with balloon compression of the rootlets behind the Gasser ganglion from 1995 to 2007 showed that balloon compression is considered in the literature to be a safer procedure than other percutaneous surgeries, especially for postoperative sensitive disorders. The best indications seem to be trigeminal neuralgia in older patients or pain due to multiple sclerosis and neuralgia involving the V1 territory(33).
According to researches at the University Clinical Centre Maribor, pain relief was reported in 25 (93%) patients. In two patients, the pain remained the same. The pain free period ranged from 2 to 74 months (median 15 months). A mean duration of analgesia was longer in patients with ideal pear shape of balloon at the time of the procedure compared to nonideal shape (P = 0.01). No major complications occurred in our group of patients(34).
In the retrospective study of 121 patients treated with balloon compression of the rootlets behind the Gasser ganglion from 1995 to 2007 showed that balloon compression is considered in the literature to be a safer procedure than other percutaneous surgeries, especially for postoperative sensitive disorders. The best indications seem to be trigeminal neuralgia in older patients or pain due to multiple sclerosis and neuralgia involving the V1 territory(33).
According to researches at the University Clinical Centre Maribor, pain relief was reported in 25 (93%) patients. In two patients, the pain remained the same. The pain free period ranged from 2 to 74 months (median 15 months). A mean duration of analgesia was longer in patients with ideal pear shape of balloon at the time of the procedure compared to nonideal shape (P = 0.01). No major complications occurred in our group of patients(34).
7. Glycerol rhizolysis
In the study to examine the pathophysiological mechanisms of trigeminal neuralgia and the mechanisms underlying pain relief after percutaneous retrogasserian glycerol rhizolysis (PRGR), indicated that relief of pain after PRGR depends on the normalization of abnormal temporal summation of pain, which is independent of general impairment of sensory perception. Assessment of the temporal summation of pain may serve as an important tool to record central neuronal hyperexcitability, which may play a key role in the pathophysiological changes in trigeminal neuralgia(35).
According to researchers at the All India Institute of Medical Sciences, seventy-nine patients underwent either PRGR (n = 40) or RF thermocoagulation (n = 39). A total of 23 patients (58.9%) in the PRGR group and 33 patients (84.6%) in the RF group experienced excellent pain relief. The mean duration of excellent pain relief in the PRGR and RF groups was comparable. By the end of the study period, 39.1% patients in the PRGR group and 51.5% patients in the RF group experienced recurrence of pain(36).
In the study to examine the pathophysiological mechanisms of trigeminal neuralgia and the mechanisms underlying pain relief after percutaneous retrogasserian glycerol rhizolysis (PRGR), indicated that relief of pain after PRGR depends on the normalization of abnormal temporal summation of pain, which is independent of general impairment of sensory perception. Assessment of the temporal summation of pain may serve as an important tool to record central neuronal hyperexcitability, which may play a key role in the pathophysiological changes in trigeminal neuralgia(35).
According to researchers at the All India Institute of Medical Sciences, seventy-nine patients underwent either PRGR (n = 40) or RF thermocoagulation (n = 39). A total of 23 patients (58.9%) in the PRGR group and 33 patients (84.6%) in the RF group experienced excellent pain relief. The mean duration of excellent pain relief in the PRGR and RF groups was comparable. By the end of the study period, 39.1% patients in the PRGR group and 51.5% patients in the RF group experienced recurrence of pain(36).
8. Radiofrequency rhizotomy
In the reevaluate the results of radiofrequency rhizotomy and review the effectiveness of other surgical procedures for the treatment of trigeminal neuralgia, Dr. Taha JM, and Dr. Tew JM Jr. at the University of Cincinnati College of Medicine, found that
1) percutaneous techniques and posterior fossa exploration offer advantages and disadvantages,
2) radiofrequency rhizotomy is the procedure of choice for most patients undergoing first surgical treatments, and
3) MVD is recommended for healthy patients who have isolated pain in the first ophthalmic trigeminal division or in all three trigeminal divisions and patients who desire no sensory deficit(37)
Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%), according to the study of Ankara University, Faculty of Medicine(38).
9. Etc.
Unfortunately, all neurosurgical interventions are helpful in relieving pain but with certain side effects. In the study to assess the efficacy of neurosurgical interventions for classical trigeminal neuralgia in terms of pain relief, quality of life and any harms and to determine if there are defined subgroups of patients more likely to benefit, showed that there is very low quality evidence for the efficacy of most neurosurgical procedures for trigeminal neuralgia because of the poor quality of the trials. All procedures produced variable pain relief, but many resulted in sensory side effects. There were no studies of microvascular decompression which observational data suggests gives the longest pain relief. There is little evidence to help comparative decision making about the best surgical procedure. Well designed studies are urgently needed(39) and various surgical procedures have been reported for the treatment of this condition, but there is no agreement on the best management of these patients. There are no differences in the short term results among different procedures for TN in MS patients. Each technique demonstrate advantages and limits in terms of long term pain, recurrence rate and complication rate(40).
In the reevaluate the results of radiofrequency rhizotomy and review the effectiveness of other surgical procedures for the treatment of trigeminal neuralgia, Dr. Taha JM, and Dr. Tew JM Jr. at the University of Cincinnati College of Medicine, found that
1) percutaneous techniques and posterior fossa exploration offer advantages and disadvantages,
2) radiofrequency rhizotomy is the procedure of choice for most patients undergoing first surgical treatments, and
3) MVD is recommended for healthy patients who have isolated pain in the first ophthalmic trigeminal division or in all three trigeminal divisions and patients who desire no sensory deficit(37)
Fifty-four of the 89 patients underwent 146 RF-TR procedures for both sides and 35 underwent 40 RF-TR procedures for one side. Complete pain relief or partial satisfactory pain relief was achieved on the medically treated side in 35 patients. During follow-up, 36 patients required the second procedure and 7 required the third procedure. Acute pain relief was reported in 86 (96.6%) patients. Early (<6 months) pain recurrence was observed in 11 (12.3%) and late (>6 months) recurrence in 25 (28.0%) patients. Complications included diminished corneal reflex in four (2.1%) patients, keratitis in two (1.1%), masseter dysfunction in four (2.1%), dysesthesia in two (1.1%), and anesthesia dolorosa in one (0.5%), according to the study of Ankara University, Faculty of Medicine(38).
9. Etc.
Unfortunately, all neurosurgical interventions are helpful in relieving pain but with certain side effects. In the study to assess the efficacy of neurosurgical interventions for classical trigeminal neuralgia in terms of pain relief, quality of life and any harms and to determine if there are defined subgroups of patients more likely to benefit, showed that there is very low quality evidence for the efficacy of most neurosurgical procedures for trigeminal neuralgia because of the poor quality of the trials. All procedures produced variable pain relief, but many resulted in sensory side effects. There were no studies of microvascular decompression which observational data suggests gives the longest pain relief. There is little evidence to help comparative decision making about the best surgical procedure. Well designed studies are urgently needed(39) and various surgical procedures have been reported for the treatment of this condition, but there is no agreement on the best management of these patients. There are no differences in the short term results among different procedures for TN in MS patients. Each technique demonstrate advantages and limits in terms of long term pain, recurrence rate and complication rate(40).
V.2. Treatment in herbal medicine perspective
The aim of herbal treatment is to relieve pain or discomfort and support the function of the peripheral nerves.
1. Corydalis yanhusuo
In the study to evaluate the analgesic effect of Corydalis yanhusuo on trigeminal neuropathic pain.in a rat mode suggested that the analgesic effect of Yanhusuo involves the participation of CB1 receptors, suggesting that Yanhusuo may offer a useful therapeutic approach for trigeminal neuropathic pain(41).
2. Uyakujunkisan (UJS)
There is a report of a 65-year-old female who developed right-sided trigeminal neuralgia that was partially responsive to carbamazepine (CZ). The pain gradually increased in intensity and at 72 years of age she presented for herbal medicine therapy. Cranial MRI demonstrated vascular compression of the right trigeminal nerve at the cerebellopontine angle by the anterior inferior cerebellar artery. Although microvascular decompression was considered, UJS was prescribed after informed consent. After 3 weeks of treatment with UJS, dramatic improvement of symptoms permitted a decrease in CZ dose(42).
3. Saiko-Keishi-To (TJ-10)
In the study to verify the effectiveness of TJ-10, Wistar rats with chronic neuralgia of the mandibular nerve were prepared and TJ-10 was administered to them for 4 weeks following the manifestation of pain in the mandibular region. The result reveals that the rise in the pain threshold in the mandibular region is more significant in the rats administered TJ-10 than in those in the control group. However, in the tail flick test, no significant change was observed in the pain threshold. These findings suggest that TJ-10 is effective for controlling the manifestation of pain in ligatured nerves, by local effect, not by general analgesic effect(43).
4. Herbal formula containing Ganoderma lucidum, WTMCGEPP
Administration of hot water extracts of a herbal formula containing Ganoderma lucidum, WTMCGEPP (Wisteria floribunda 0.38, Trapa natans 0.38, Miristica agrans 0.38, Coix lachryma-jobi 0.75, cultivated Ganoderma lucidum 0.75, Elfuinga applanata 0.38, tissue cultured Panax ginseng 0.3, and Punica granatum 0.38: numerals designate dry weight gram/dose), decreased herpes zoster pain for five Japanese patients suffering from shingles. Pain relief started within a few days of intake and was almost complete within 10 days. Two acute herpes zoster with manifestations including trigeminal nerve ophthalmia (both 74 years old), lower body zoster (70 years old), herpes zoster oticus (17 years old), and leg herpes (28 years old), responded quickly to treatment and no patient developed post-herpetic neuralgia (PHN) after more than one year of follow-up(44)
5. Etc.
V.3. Treatment in traditional Chinese perspective
1. Siwei Shaoyao Decoction
Siwei Shaoyao Decoction possesses a marked effect on the alleviation of trigeminal neuralgia in rats caused by penicillin G potassium injection. As shown from the hot-plate test, it also has an obvious analgesic effect on mice. To some extent, the decoction has a significant anti-inflammatory effect on the acute edema in hind paws of rats and the effect is believed to be related to the reduction of capillary permeability, according to the study by Guiyang College of Traditional Chinese Medicine(45)
2. Sanchaning
In an experimental study and the comparision of the effect of Sanchaning with that of distilled water as well as carbamazepine, a common Western medicine for curing PTN, Sanchaning differed significantly from distilled water in treating PTN (P < 0.01), but slightly differed from that of carbamazepine (P < 0.05). The sequential trial has identified that Sanchaning could be used effectively to inhibit PTN and has the same effect as carbamazepine. But further study should be carried out to investigate the mechanism of its function in relieving PTN(46).
3. Yokukansan (Yi-Gan San)
According to the report of Juntendo University School of Medicine, the efficacy of Yokukansan in patients with neuropathic pain, including acute herpetic pain, postherpetic neuralgia, central poststroke pain, post-traumatic spinal cord injury pain, thalamic syndrome, complex regional pain syndrome and symptomatic trigeminal neuralgia. Yokukansan was more effective compared with traditional medicines, such as tricyclic antidepressants, carbamazepine, gabapentin, and opioids etc., which are recommended to treat neuropathic pain(47).
4. Etc.
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