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- Abrasions, anal fissure, autolytic debridement, bed sore, Clostridium sp., collagen, collagen matrix, cuts, debridement, decubitus ulcer, diabetic ulcers, electrotherapy, epithelial, epithelialization phase, extravasation, gangrene, gas gangrene, human growth factors, hydrocolloid, hyperbaric oxygen, incision wounds, incontinence, infected surgical wounds, infectious arthritis, inflammatory phase, injuries, laceration, macrophages, mechanical debridement, microvascular, minor injuries, myonecrosis, necrotizing fasciitis, pressure ulcers/wound care, proliferative phase, puncture wound, remodeling phase, scrapes, scratches, sepsis, septic arthritis, skin damage caused by incontinence, skin graft healing (split thickness), skin ulcer, surgical skin flap ischemia, skin wounds, squamous, stitches, superficial, suture, vulnerary, wound care, wound healing.
- A wound is a break in the outer layer of the skin, called the epidermis. Wounds are usually caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending upon how they happened and how serious they are. Other wounds include puncture wounds, lacerations (cuts), pressure sores, anal fissures, extravasations (a drug accidentally going outside of a vein causing tissue damage), skin damage caused by incontinence (lack of bladder control), skin graft healing (split thickness), diabetic ulcers, and surgical skin flap ischemia (lack of blood flow to surgically attached skin).
- Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone, all tissues heal with some external scarring. The object of proper care is to minimize the possibility of infection and scarring.
- There are basically four phases to the healing process: the inflammatory phase, proliferative phase, remodeling phase, and epithelialization phase.
- The inflammatory phase begins with the injury itself. In the inflammatory phase, there is bleeding, immediate narrowing of the blood vessels, clot formation, and release of various chemical substances into the wound that will begin the healing process. Specialized cells (macrophages) clear the wound of debris over the course of several days.
- Next is the proliferative phase in which a matrix or latticework of cells forms. On this matrix, new skin cells and blood vessels will form. It is the new small blood vessels (known as capillaries) that give a healing wound its pink or purple-red appearance. These new blood vessels will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and support the production of proteins (primarily collagen). The collagen acts as the framework upon which the new tissues build. Collagen is the dominant substance in the final scar.
- The remodeling phase begins after 2-3 weeks. The framework (collagen) becomes more organized making the tissue stronger. The blood vessel density becomes less, and the wound begins to lose its pinkish color. Over the course of six months, the area increases in strength, eventually reaching 70% of the strength of uninjured skin.
- Epithelialization is the process of laying down new skin, or epithelial, cells. The skin forms a protective barrier between the outer environment and the body. Its primary purpose is to protect against excessive water loss and bacteria. Reconstruction of this layer begins within a few hours of the injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take 7-10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring occurs when the injury extends beyond the deep layer of the skin (into the dermis, which is the second layer of skin).
- Unclear or conflicting scientific evidence:
- Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Study results of aloe on wound healing are mixed with some studies reporting positive results and others showing no benefit or potential worsening of the condition. Early studies suggest that aloe may help heal skin ulcers. High-quality studies comparing aloe alone with placebo are needed.
- Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Do not apply to open skin, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools or hepatitis. Avoid with a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
- Alpha-lipoic acid: Alpha-lipoic acid (ALA) may reduce tissue damage that is often caused by long-term exposure to high levels of oxygen. While early studies are promising, more research is needed to fully understand how ALA might work for wound healing in patients undergoing hyperbaric oxygen therapy.
- Avoid if allergic to alpha-lipoic acid (ALA). Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.
- Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required (for example, due to inborn errors of urea synthesis, protein malnutrition, excess ammonia production, excessive lysine intake, burns, infection, peritoneal dialysis, rapid growth, or sepsis). Arginine has been suggested to improve the rate of wound healing in elderly individuals. A randomized, controlled clinical trial reported improved wound healing after surgery in head and neck cancer patients, following the use of an enteral diet supplemented with arginine and fiber. Arginine has also been used topically (on the skin) to attempt to improve wound healing. Early studies suggest that arginine may also help treat chronic anal fissures. Additional studies are needed.
- Avoid if allergic to arginine, or with a history of stroke, liver, or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.
- Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary data from one small study suggests aromatherapy may contribute to reduced pain intensity during dressing changes in wound care. Data are insufficient for forming any opinion for or against this application.
- Essential oils should only be used on the skin in areas without irritation. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving or operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
- Ayurveda: There is some evidence that a traditional Ayurvedic treatment using specially prepared alkaline threads (ksharasutra or Ayurvedic setons) to achieve gradual cauterization may provide an effective alternative to surgery in patients being treated for anal fissures. Further research is needed to confirm these results.
- Ayurvedic herbs should be used cautiously. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking. Use guggul cautiously with peptic ulcer disease. User should avoid sour food, alcohol and heavy exercise. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia hebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.
- Bovine cartilage: Reduction in inflammation and edema (swelling) and enhancement of the healing of wounds were effects that appeared in the medical literature of bovine cartilage during the 1950s and 1960s. In a preliminary comparison of potential wound healing effects with a commercially available ointment of 10% powdered bovine cartilage (Catrix® 10 Ointment) or Aquaphor® original formula in post-operative facial skin care with a laser resurfacing agent, Catrix® 10 Ointment was better. However, this study was a pilot study so its results need confirmation by follow-up clinical studies that clearly have the appropriate randomization and are double-blinded, given that such were in absence in this study. Also lacking in this study was a definition of primary outcome that therapeutically differentiated Catrix® 10 Ointment.
- Avoid if allergic or hypersensitive to bovine cartilage or any of its constituents. Use cautiously with cancer, renal (kidney) failure, or hepatic (liver) failure. Avoid if pregnant or breastfeeding.
- Calendula: Calendula (Calendula officinalis), also known as pot marigold, has been widely used on the skin to treat minor wounds, skin infections, burns, bee stings, sunburn, warts, and cancer. Calendula is commonly used topically (on the skin) to treat minor skin wounds. Reliable human research is necessary before a firm conclusion can be drawn regarding the use of calendula for wound healing.
- Avoid if allergic to plants in the Aster/Compositae family, such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously with diabetes and in children. Avoid if pregnant or breastfeeding.
- Chamomile: Chamomile (Matricaria recutita, Chamaemelum nobile) has been used medicinally for thousands of years, and is widely used in Europe. There is promising preliminary evidence supporting the topical use of chamomile for wound healing. However, the available literature is not adequate to support the use of chamomile for this indication.
- Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash can cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.
- Chitosan: There is limited evidence on the effects of chitosan in wound healing. Better studies are needed.
- Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously with diabetes or bleeding disorders. Use cautiously if taking drugs, herbs, or supplements that lower blood sugar or increase the risk of bleeding. Chitosan may decrease absorption of fat and fat-soluble vitamins from foods. Chitosan is not recommended during pregnancy or breastfeeding.
- Dimethylsulfoxide (DMSO): Dimethylsulfoxide (DMSO) is a sulfur-containing organic compound. DMSO occurs naturally in vegetables, fruits, grains, and animal products. DMSO applied to the skin may prevent tissue death after extravasation of anticancer agents. It can be applied alone or with steroids. Limited available study also suggests that DSMO improves lack of blood flow in surgical skin flap ischemia. Currently, there is not enough scientific evidence available for the use of topical DMSO for diabetic ulcers.
- Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.
- Eucalyptus oil: Eucalyptus (Eucalyptus globulus) oil contains 70-85% 1,8-cineole (eucalyptol), which is also present in other plant oils. Limited evidence suggests that eucalyptus essential oil may be beneficial for patients with skin ulcers when combined with antibiotics. More studies are needed to confirm these early findings.
- Case reports describe allergic rash after exposure to eucalyptus oil, either alone or as an ingredient in creams. Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.
- Gotu kola: Gotu kola, Centella asiatica (formerly known as Hydrocotyle asiatica), has a long history of use, dating back to ancient Chinese and Ayurvedic medicine. Preliminary study has demonstrated the ability of Centella asiatica extracts to promote wound healing, possibly through the stimulation of collagen synthesis. However, additional human study is needed in this area.
- Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.
- Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis melliflera) from the nectar of flowers. The primary studied use of honey is for wound management, particularly in promoting rapid wound healing, deodorizing, and debriding necrotic tissue. The types of wounds studied are varied; most are non-healing wounds such as chronic ulcers, postoperative wounds, and burns. Currently, there is insufficient human evidence to support the use of honey for skin graft healing. Although honey has apparent antibacterial effects, more human study is needed in this area.
- Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
- Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. These approaches have been used for the relief of various diseases and injuries, or for general well being. Hydrotherapy has been used in patients with pressure ulcers, and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn.
- There is a risk of infection from contaminated water if sanitary conditions are not maintained. Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
- Iodine: It is not clear if healing of wounds or skin ulcers is improved with the application of topical iodine solutions. Iodine solutions may assist with sterilization as a part of a larger approach to the wound healing process.
- Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.
- Magnet therapy: The use of magnets to treat illness has been described historically in many civilizations. In modern times, magnetic fields play an important role in Western medicine, including use for magnetic resonance imaging (MRI), pulsed electromagnetic fields, and experimental magnetic stimulatory techniques. Early scientific evidence suggests that the time to heal wounds, including ulcers, may decrease with the use of static magnets. Better quality studies are needed before a firm recommendation can be made for wound healing.
- Avoid with implantable medical devices, such as heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
- Pantothenic acid (vitamin B5): Pantothenic acid (vitamin B5) is essential to all life and is a component of Coenzyme A (CoA), a molecule that is necessary for numerous vital chemical reactions to occur in cells. Pantothenic acid is essential to the metabolism of carbohydrates, proteins, and fats, as well as for the synthesis of hormones and cholesterol. In animal research, oral and topical pantothenic acid has been associated with accelerated skin wound healing. However early human study results conflict. Additional evidence is necessary before a clear conclusion can be reached regarding this use of pantothenic acid or dexpanthenol.
- Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.
- Papain: Papain is an enzyme that breaks protein bonds and has been used in Africa for treating burns. In standard western medical care, papain-containing debridement agents are commonly used to remove necrotic tissue and slough in burns, postoperative wounds, pilonidal cyst wounds, carbuncles, trauma wounds, infected wounds, and chronic lesions, such as pressure ulcers, and varicose and diabetic ulcers. According to reviews and clinical trials, papain may be very useful for wound debridement and for stimulating wound healing. More high-quality research is needed in this area.
- Use cautiously in patients sensitive to papain. Use cautiously in patients being treated for prostatitis. Use Wobenzym®, which contains papain, cautiously, especially in those with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease. Avoid in patients using immunosuppressive therapy.
- Physical therapy: Physical therapy techniques, such as laser treatment, have been used to clean and heal wounds. Early evidence also suggests that high voltage stimulation or pulsed electrical stimulation may speed the healing of some types of skin ulcers. More research with similar outcome measures is needed to better understand the role of physical therapy for wound care.
- Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
- Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber, and is the chief ingredient in many commonly used bulk laxatives. Results from human study suggest that psyllium may reduce the number of surgeries necessary to heal anal fissures. Further evidence is necessary.
- Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantains (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
- Rose hip: Rose hips are the fruits that develop from the blossoms of the wild rose (Rosa spp.). They are typically orange to red in color, but some species may be purple or black. When applied topically, the volatile oils of aromatic plants may have physiological effects that will facilitate wound healing. Rose hips contain several vitamins and minerals, including vitamin C, vitamin B1, vitamin E, calcium, zinc, and carotenoids, which could potentially promote wound healing when applied to the skin. Much larger and high quality clinical trials are needed to establish the therapeutic efficacy of rose hip and rose oil preparations in the topical treatment of surgical wounds and ulcers.
- Use cautiously in patients who are avoiding immune system stimulants. Use cautiously in patients who are taking anticoagulant or anti-platelet aggregating agents, antibiotics, antineoplastics, antiretrovirals, anti-inflammatory agents, "Long-Life CiLi", antilipemics, aluminum-containing antacids, salicylates, or laxatives. Avoid in patients who are allergic to rose hips, rose pollen, its constituents, or members of the Rosaceae family.
- TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat pain, as an alternative or addition to pain medications. Therapy sessions may last from minutes to hours. TENS is often used in conjunction with acupuncture therapy. TENS has been tested for its effects on blood flow to skin flaps used in plastic surgery procedures such as breast reconstruction. TENS has also been evaluated in patients with skin ulcers, diabetic foot ulcers, and chronic ulcers of various causes. More research is needed in this area.
- Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
- Therapeutic touch: Although some studies report an improvement in wound healing with therapeutic touch, others show no benefits.
- Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
- Vitamin A: In preliminary study, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound healing effects. Further research is needed to confirm these results.
- Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease. Vitamin A appears to be safe in pregnant women if taken at recommended doses; however, vitamin A excess, as well as deficiency, has been associated with birth defects. Excessive doses of vitamin A have been associated with central nervous system malformations. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.
- Zinc: Although zinc is frequently cited as having beneficial effects on healing of incision wounds, few studies have investigated this use. Further research is needed. There are conflicting findings regarding the potential benefit of zinc for healing leg ulcers. Available studies reported no or few adverse effects.
- Preliminary evidence suggests that topical zinc oxide oil may help manage perianal and buttock skin damage in incontinent patients. Further research is needed to better understand the role of zinc for treatment of skin damage caused by incontinence.
- Zinc is generally considered to be safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
- Fair negative scientific evidence:
- Aloe: A well-designed human trial found no benefit of topical acemannan hydrogel (a component of aloe gel) in the treatment of pressure ulcers.
- Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Do not apply to open skin, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools or hepatitis. Avoid with a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
- In order to prevent wounds from occurring, healthcare providers recommend that individuals: take care when using sharp objects such as knives, scissors, saws, and trimmers; wear shoes or boots on the feet; use helmets when riding a bicycle; use helmets, kneepads, wrist protectors, and elbow pads when using in-line skates or skateboards; and avoid picking up broken pieces of glass and handling razor blades.
- If bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, healthcare providers recommend that the individual be checked for pressure sores every day. Also, look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. In addition, take the following steps: change position at least every two hours to relieve pressure; use items that can help reduce pressure such as pillows, sheepskin, foam padding, and powders from medical supply stores; eat healthy, well-balanced meals; exercise daily, including range-of-motion exercises for immobile patients; and keep skin clean and dry. Incontinent people need to take extra steps to limit moisture.
- Individuals with diabetes should check their feet daily for blisters, sores, or other wounds in order to prevent serious infection and possibly amputation.
- This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
- American Academy of Family Physicians. .
- American Academy of Pediatrics. .
- Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg. 2006;117(7 Suppl):42S-58S.
- Centers for Disease Control and Prevention. .
- Dini V, Bertone M, Romanelli M. Prevention and management of pressure ulcers. Dermatol Ther. 2006;19(6):356-64.
- Langemo D, Anderson J, Hanson D, et al. Nutritional considerations in wound care. Adv Skin Wound Care. 2006;19(6):297-8, 300, 303.
- de Laat EH, Schoonhoven L, Pickkers P, et al. Epidemiology, risk and prevention of pressure ulcers in critically ill patients: a literature review. J Wound Care. 2006;15(6):269-75.
- Natural Standard: The Authority on Integrative Medicine. .
- National Institute of Allergy and Infectious Diseases. .
- Pieper B, Sieggreen M, Nordstrom CK, et al. Discharge knowledge and concerns of patients going home with a wound. J Wound Ostomy Continence Nurs. 2007;34(3):245-53; quiz 254-5.
- Wu SC, Driver VR, Wrobel JS, et al. Foot ulcers in the diabetic patient, prevention and treatment. Vasc Health Risk Manag. 2007;3(1):65-76.
- Overview: Cholecystitis is the inflammation of the gallbladder wall and nearby abdominal lining.
- Causes: Most cases of cholecystitis occur when a gallstone becomes lodged in the cystic duct, which is the tube that connects the gall bladder to the common bile duct. Other less common causes include bacterial infections in the bile duct system, tumors of the liver or pancreas, or decreased blood supply to the gallbladder. Diabetics have an increased risk of developing a decreased blood supply to the gallbladder.
- Symptoms: Symptoms may develop suddenly or gradually over the course of several years. Most cholecystitis attacks last one to two days. Common symptoms include severe pain in the upper right part of the abdomen after meals that usually lasts for several hours, nausea, vomiting, mild fever, rigid abdominal muscles, yellowing of the skin and eyes (jaundice), and loose, light-colored bowel movements. In rare cases, cholecystitis may cause itching, especially in the hands and feet.
- Diagnosis: There are several tests available to detect abnormalities of the gallbladder. After a detailed medical history and physical examination are performed, the healthcare provider determines the appropriate tests needed to diagnose the underlying cause.
- An ultrasound, which involves rubbing a wand-like instrument (called a transducer) over the lower abdomen, may be performed to take pictures of the gallbladder.
- Patients may also undergo a computerized tomography (CT) scan that takes pictures of the internal organs. A dye is often injected into the patient before the CT scan is performed to help the healthcare provider view the tubes and organs of the biliary system in more detail.
- An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at a hospital to check for problems in the liver, gallbladder, bile ducts, and pancreas. During the procedure, a thin, flexible tube with a camera at the tip (called an endoscope) is inserted through the mouth and into the small intestine until it reaches the biliary ducts and pancreas. A small plastic tube is then inserted through the endoscope and a colored dye is injected. This allows the healthcare provider to see detailed images of the biliary tract.
- If the patient has a fever in addition to cholecystitis symptoms, a blood culture may be performed to diagnose an infection. A sample of the patient's blood is analyzed for the presence of disease-causing microorganisms.
- Treatment: Treatment depends on the underlying cause. Infections are treated with medications called antibiotics. The specific dose and type of antibiotic used depends on the specific type and severity of the infection.
- If a gallstone is causing the condition, the gallbladder is usually surgically removed. If the gallbladder is removed, patients can expect a full recovery. Complications are rare but may include damage to the common bile duct, bleeding, and infection. Non-surgical procedures, such as bile salt tablets and sound wave therapy, are only considered if the patient is unable to undergo surgery or the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
- Overview: Cholestasis occurs when the flow of digestive fluid produced by the liver (called bile) is either limited or stopped at some point between the liver and the small intestine. As a result, a waste product, called bilirubin, leaks into the bloodstream where it accumulates.
- Bilirubin is yellow to green in color. When it leaks into the bloodstream, it may cause the skin and eyes to become yellow in color.
- Causes: Cholestasis may be caused by problems in or outside of the liver the liver. For instance, acute liver inflammation (hepatitis), alcoholic liver disease, primary biliary cirrhosis, cirrhosis of the liver, certain medications (e.g. birth control pills or an antipsychotic and antinausea drug called chlorpromazine), hormonal changes during pregnancy, and cancer that has spread to the liver, may cause cholestasis.
- Problems outside of the liver, such as gallstones, narrowing of a bile duct, cancer of a bile duct, cancer of the pancreas, and inflammation of the pancreas (pancreatitis), may cause cholestasis.
- Symptoms: Many times the only symptom noticed is itchy skin (especially on the hands and feet). This is because waste products from the bile leak into the bloodstream and irritate the skin. Other symptoms may include yellowing of the eyes and skin (jaundice), light-colored stools, oily and foul-smelling stools (steatorrhea), dark urine, abdominal pain, vomiting, loss of appetite, and fever.
- Bile is needed to emulsify fats, as well as calcium, vitamin D, and vitamin K from foods. This process allows the intestines to absorb important nutrients. When not enough bile is released into the intestine, these vitamins are unable to be absorbed into the blood. If left untreated, these nutrient deficiencies may lead to the development of weak or brittle bones or increased bleeding.
- Diagnosis: Blood tests can confirm a diagnosis of cholestasis. Patients with the disorder typically have high levels of two liver enzymes: alkaline phasphatatase and gamma-glutamyl transpeptidase. Patients with cholestasis generally have three times the normal amount of alkaline phosphatase in their blood. Healthy individuals have 44-147 international units of alkaline phosphatase per liter of blood and 0-51 international units of gamma-glutamyl transpeptidase.
- A healthcare provider may be able to tell if the condition is caused by an obstruction inside or outside of the liver after a detailed medical history and physical examination. If the patient has a history of hepatitis or alcoholism or is taking new drugs, an obstruction in the liver is usually suspected. If the physical examination shows that the gallbladder is rigid or painful, an obstruction outside of the liver is suspected.
- Additional tests, such as a computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, or ultrasound, may be performed to help determine the underlying cause of the condition. If it is suspected that the ducts in the liver are blocked, a liver biopsy may be performed to confirm a diagnosis. If it is suspected that the bile ducts are blocked, either an endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) is performed. Both of these tests provide detailed images of the gallbladder ducts.
- Treatment: Treatment of cholestasis depends on the underlying cause.
- If a gallstone is blocking the flow of bile, the gallbladder is usually surgically removed. If the gallbladder is removed, patients can expect a full recovery. Complications are rare but may include damage to the common bile duct, bleeding, and infection.
During the procedure, a flexible tube called an endoscope is inserted through the anus. Additional surgical tools are inserted through the tube to remove the gallbladder. Non-surgical procedures, such as bile salt tablets and sound wave therapy, are only considered if the patient is unable to undergo surgery or the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
- If a medication (e.g. birth control pills or chlorpromazine) is the suspected cause, a healthcare provider may recommend switching to an alternative drug. Patients should not stop taking their medications or change their doses without first consulting their healthcare providers.
- If hepatitis is causing the condition, symptoms will resolve once the swelling and/or infection resolves. In general, there are few treatment options for hepatitis. Patients may receive medications, including antivirals and immunomodulators (e.g. interferons), but they are not always effective.
- Calcium, vitamin D, and/or vitamin K supplements may be necessary if the patient has nutritional deficiencies. Patients should only take supplements under the strict supervision of their healthcare providers.
- In addition, a medication called cholestyramine (Questran®) may be taken by mouth to reduce itchiness associated with cholestasis. This medication binds with certain substances in the bile, preventing them from being reabsorbed to irritate the skin. It remains unknown if cholestyramine is safe for pregnant or breastfeeding women.
- Patients with cholestasis should avoid substances that may be toxic to the liver, including certain medications (e.g. chlorpromazine) and alcohol, because they may worsen symptoms.
- Overview: A gallbladder attack, also called gallbladder colic, is characterized by pain and nausea and may accompany many types of gallbladder disorders.
- Causes: A gallbladder attack may occur when a gallstone moves through the biliary tract towards the small intestine or if the gallbladder becomes inflamed (a condition called cholescystitis). An attack may also be the result of cholestasis, which occurs when the flow of bile is blocked or if the gallbladder becomes inflamed (cholecystitis).
- Symptoms: Gallbladder attacks generally last one to four hours. Common symptoms include dull, sharp, or excruciating pain on the right side of the abdomen, as well as nausea, vomiting, and bloating. The gallbladder, which is located in the lower right side of the abdomen, is usually tender to the touch. It is common for pain to radiate to the right shoulder blade.
- Diagnosis: A healthcare provider will be able to tell if a patient is having gallbladder attacks after a detailed medical history and physical examination are performed. The next step is to determine the underlying cause of the symptoms.
- Blood tests are usually performed to determine if the patient has cholestasis. Patients with cholestasis typically have high levels of two liver enzymes: alkaline phosphatase and gamma-glutamyl transpeptidase. Healthy individuals have 44-147 international units of alkaline phosphatase per liter of blood and 0-51 international units of gamma-glutamyl transpeptidase per liter of blood.
- A computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, or ultrasound may also be performed. These tests produce images of the internal organs and may help the healthcare provider detect abnormalities, such as gallstones, that may be causing the gallbladder attack.
- Endoscopic retrograde cholangiopancreatography (ERCP) may be performed at a hospital to check for problems in the liver, gallbladder, bile ducts, and pancreas. During the procedure, a thin, flexible tube with a camera (called an endoscope) is inserted through the mouth into the small intestine until it reaches the bile ducts and pancreas. A small plastic tube is inserted through the endoscope and a colored dye is injected. This allows the healthcare provider to see detailed images of the biliary tract.
- Treatment: Treatment of gallbladder attacks depends on the underlying cause. For instance, if a gallstone is causing a gallbladder attack, the gallbladder is usually surgically removed. Antibiotics may be prescribed if an infection is the cause. The type of antibiotic used depends on the specific type of infection and severity of the condition. If a medication is the suspected cause, a healthcare provider may recommend an alternative dose or different medication.
- Overview: Gallstones, also called cholelithiasis, develop when small particles of the bile in the gallbladder solidify into a stone-like mass. Sometimes gallstones are too large to pass through the biliary ducts and the stone becomes stuck inside the tubes in the gallbladder. In such
cases, surgery is necessary to remove the gallbladder.
- Causes: Bile consists of bile salts and a fatty compound called lecithin. Lecithin is needed to dissolve the cholesterol in the bile excreted by the liver. Individuals may develop gallstones if there is more cholesterol in the bile than can be dissolved. It is important to note that cholesterol in the blood is not related to cholesterol in the liver. If patients have high levels of cholesterol in the liver it does not mean that they have high levels of cholesterol in the blood. In healthy individuals, the liver is able to control the amount of cholesterol produced in order to keep levels constant. Therefore, cholesterol-lowering drugs cannot prevent gallstones from developing.
- Gallstones may also develop if the gallbladder does not empty completely or often enough. When this happens, the bile may become too concentrated. This is especially common among pregnant women because high levels of estrogen during pregnancy increases bile cholesterol levels and decreases the number of the times the gallbladder empties. Also, eating too little fat or not eating for extended periods of time may also increase the risk gallstones because it causes the gallbladder to empty less frequently.
- Symptoms: If the biliary ducts become blocked with a gallstone, bile flow is disrupted. As a result, the bile duct muscles continually contract to try to force the bile through the tubes. This causes a sudden, steady, moderate, or intense pain in the abdomen (called biliary colic or a gallbladder attack). Most pain is felt in the upper or middle abdomen. In some cases, the pain may radiate to the right shoulder blade. Although pain may develop at any time, it is usually felt a couple hours after eating. Pain may last anywhere from 15 minutes to several hours. Some patients may develop nausea and vomiting during an attack. Once the pain goes away, patients may continue to feel a mild aching or soreness in the abdomen for about one day.
- Diagnosis: There are several tests available to diagnose gallstones. An ultrasound is typically performed. During the procedure, a wand-like device, called a transducer, is rubbed over the abdomen. Sound waves produce images of the internal organs, including the gallbladder, and the healthcare provider is able to detect gallstones.
- Additional test may also be performed such as a computerized tomography (CT) scan. A CT scan produces detailed images of the internal organs.
- A radionuclide scan (also called a cholesintigraphy, hydroxyl iminodiacetic acid scan, or HIDA scan) may be performed. During a radionuclide scan, the patient is injected with a radioactive dye, called HIDA, because it accumulates in the liver and biliary system. Pictures of the abdomen are then taken. This dye is visible in the ducts and organs in the abdomen. If a gallstone is present in the cystic duct, the dye will not make it all the way to the gallbladder. The amount of radiation emitted during the test is less than that of an X-ray. However, most healthcare providers do not perform this test in pregnant or breastfeeding mothers unless it is absolutely necessary.
- Treatment: If the gallstone is blocking a biliary duct, the gallbladder is usually surgically removed. A procedure called endoscopic sphincterotomy is most often performed. During the procedure, which is performed at a hospital, the patient receives general anesthesia. Then, a thin, flexible tube called an endoscope is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallbladder. The gallbladder may also be removed through an incision in the abdomen. However, this type of surgery is performed less often because it is more invasive and requires a longer recovery time than an endoscopic sphincterotomy.
- Once the gallbladder is removed, patients can expect a full recovery. Some patients may experience more frequent bowel movements and/or loser-than-normal stools or diarrhea. In some cases, these symptoms may gradually improve over time. Complications are rare but may include damage to the common bile duct, bleeding, and infection.
- Non-surgical procedures, such as bile salt tablets or sound wave therapy, are only considered if the patient is unable to undergo surgery or if the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
- Bile salt tablets called ursodiol (Actigall®) may be taken by mouth to dissolves cholesterol gallstones. In order to prevent gallstones from recurring, most patients need to take the medication daily for the rest of their lives.
- Patients with cholesterol gallstones may undergo a procedure called extracorporeal shock wave lithotripsy (ESWL). Sound waves (shock waves) are used to break the stone into smaller pieces. Patients receive sedatives and/or anesthesia before the procedure. The patient will either be partially submerged in a tub of water or will lie on a soft cushion. Patients wear headphones because the shock waves are loud. High-energy sound waves then pass through the patient's body and break the stone into smaller pieces. The healthcare provider usually uses X-rays or an ultrasound to ensure that the stone breaks down. Treatment usually lasts for about one hour. Patients then take ursodiol (Actigall®) daily for the rest of their lives to help prevent the gallstones from recurring.
- Side effects of shock wave therapy include blood in the urine, bruising on the abdomen or back, bleeding around the kidney or nearby organs, and pain when the stone fragments are passed in the urine. This therapy is not recommended for pregnant women or patients with cholecystitis or cholangitis.
- Overview: Gilbert's syndrome is a common inherited disorder that occurs when the liver is unable to properly process the yellow-green pigments in bile (called bilirubin). The increased levels of bilirubin in the bloodstream may lead to yellowing of the skin (jaundice), but the liver itself remains normal. In fact, this condition is so mild that is not usually considered a disease.
- Causes: Gilbert's syndrome is an inherited disorder, which is why it is more common among men than women. The condition is passed down as an autosomal dominant trait. This means patients only need to inherit one copy of the mutated gene in order to develop Gilbert's syndrome.
- Several factors may worsen symptoms of Gilbert's syndrome by slightly increasing the amount of bilirubin in the blood. Examples include illnesses (e.g. the common cold or the flu), fasting or skipping meals, menstruation, dehydration, or overexertion.
- Symptoms: Gilbert's syndrome rarely causes any symptoms. Some patients may periodically develop a condition called jaundice, which causes the skin and eyes to appear yellow.
- Although some patients experience periods of fatigue and abdominal pain, it is unclear if they are related to Gilbert's syndrome.
- Diagnosis: Gilbert's syndrome is diagnosed after a blood test. Patients with the condition will have more than 0.3-1.9 milligrams of total bilirubin per deciliter of blood and more than 0-0.3 milligrams of direct bilirubin per deciliter of blood. However, levels of bilirubin normally fluctuate throughout the day. Therefore, if Gilbert's syndrome is strongly suspected but initial results are normal, repeat testing may be recommended at a different time of day.
- Treatment: Gilbert's syndrome generally does not require treatment. Even if a patient experiences periods of jaundice, each symptomatic episode is very mild and will go away in a few days.
- Overview: Pancreatitis is severe inflammation of the pancreas. When the pancreas becomes inflamed, the digestive enzymes in the organ become active too soon. Instead of becoming active in the intestines, they become active inside the pancreas, where they can cause organ damage.
- Once the underlying cause is treated, most patients experience a full recovery. However, if the condition is left untreated, scarring may occur in the pancreas. Once the organ becomes scarred, the condition cannot be reversed and the patient will require long-term treatment to manage the symptoms.
- Causes: Alcohol is the leading cause of pancreatitis. Individuals who drink heavily for many years have an increased risk of developing it. It is not clear exactly how alcohol affects the pancreas. However, researchers have found that alcohol causes digestive enzymes to be released sooner than normal. Alcohol also increases the permeability of the small ducts. As a result, the pancreatic digestive enzymes are able to damage healthy tissues inside the pancreas. In addition, alcohol abuse has been shown to cause protein plugs, which may develop into gallstones.
- Gallstones are another common cause of pancreatitis. Gallstones develop when small particles of the bile in the gallbladder solidify into a stone-like mass. Sometimes the gallstones move from the gallbladder to a small tube called the common bile duct. This common bile duct connects to another tube called the pancreatic duct. If the stone blocks the pancreatic duct, it causes the pancreas to become inflamed. If left untreated, enzymes may leak from the pancreas and damage healthy tissues.
- Some medications, including antibiotics such as pentamidine (Pentam®) and the anti-HIV drug didanosine (Videx®), have been shown to cause pancreatitis. Also, studies have shown that some drugs, including the antiretroviral tenofovir (Viread®) and the anti-cancer drug hydroxyurea (Droxia® or Hydrea®), may increase the amount of didanosine in the blood, which further increases the risk of pancreatitis
- Symptoms: Acute symptoms of pancreatitis appear suddenly and may lasts for several hours or even days. Common symptoms include nausea, rapid pulse, fever, vomiting, and severe abdominal pain and swelling. The abdomen may be tender when touched. Drinking alcohol causes the symptoms to worsen.
- If the underlying cause of pancreatitis is not treated, the condition may become chronic (long-term). Common symptoms of chronic pancreatitis include nausea, vomiting, fever, and unintentional weight loss. Chronic pancreatitis may lead to temporary diabetes, malnutrition, and severe pain.
- Diagnosis: A blood test may be performed to determine if there are elevated levels of the pancreatic enzymes amylase and lipase in the blood. Patients with pancreatitis will test positive for these enzymes.
- Imaging studies, such as an abdominal X-ray or computerized tomography (CT) scan, may be performed to determine whether the pancreas is larger than normal. Both of these tests, which are performed at a hospital, produce images of the internal organs. Patients with pancreatitis will have an inflamed pancreas.
- An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at a hospital to evaluate the damage of the pancreas. During the procedure, a thin, flexible tube with a camera is inserted through the mouth into the small intestine until it reaches the bile ducts and pancreas. During the test, a small tissue sample may be removed and analyzed in a laboratory for infections or cancer. Because this procedure may damage the pancreas if not performed by a qualified physician, it is only conducted if all other tests are inconclusive. There is also a slight risk of infection.
- Treatment: There is no cure for chronic pancreatitis. However, alcohol avoidance and pain medications can effectively relieve symptoms of the condition.
- Acute pancreatitis usually improves after about one week of treatment.
- If a medication, such as pentamidine (Pentam®) or the anti-HIV drug didanosine (Videx®), is suspected to be causing acute pancreatitis, a healthcare provider may recommend switching to an alternative dose or medication. Patients should not stop taking medications or take different dosages without first consulting their healthcare providers.
- Antimicrobials are used to treat infections that cause pancreatitis. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections. The exact type of medication and length of treatment depends on the type and severity of the infection, as well as the patient's overall health.
- If a gallstone is causing acute pancreatitis, the gallbladder is usually surgically removed. A surgical procedure, called endoscopic sphincterotomy, is most often performed. During the procedure, which is performed at a hospital, the patient receives general anesthesia and is asleep during the surgery. Then, a thin flexible tube, called an endoscope, is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallbladder. Non-surgical procedures are only considered if the patient is unable to undergo surgery or if the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
- Overview: Bile reflux is a condition in which bile, a fluid that helps digest fats, flows upward from the small intestine into the stomach and esophagus. Bile reflux disease may cause or occur simultaneously with gastritis, causing further irritation and inflammation. Because bile reflux and acid reflux may occur together, the patient is at a higher risk for developing esophageal complications.
- Causes: Bile reflux most often occurs when the pyloric valve (a ring of muscle that separates the stomach from the duodenum) or the lower esophageal sphincter (an opening which separates the esophagus and stomach) do not function properly, which causes backflow of bile into the stomach and esophagus. Bile reflux has also been found to be common after gallbladder removal, or as a result of complications from gastric surgery which may damage the pyloric valve such as gastrectomy, or gastric bypass. Further inflammation and damage to the lining of the stomach and esophagus may occur as a result.
- Symptoms: Symptoms of bile reflux may include a burning, biting, or gnawing pain in the upper abdomen, nausea, frequent heartburn, vomiting of bile, and a dry hacking cough. Symptoms may be very similar to acid reflux, making it difficult to distinguish one condition from the other, especially because both frequently occur together.
- Diagnosis: Diagnosis of bile reflux is often difficult to distinguish from gastritis or acid reflux, because they may both occur simultaneously. Common tests assess damage to the esophagus and stomach and may include endoscopy, ambulatory acid tests, and esophageal impedance tests.
- Treatment: Bile reflux is generally not known to be completely treated solely by dietary or lifestyle changes such as smoking cessation, alcohol avoidance, eating smaller, healthier (lower fat) meals, weight reduction and relaxation, although these methods may provide relief of symptoms. Rather, bile reflux is often managed with medications or surgery in cases where other treatments have failed. Because bile reflux and gastritis often occur together, there may be some overlap in treatment approaches.
- Prescription medications include ursodeoxycholic acid to promote bile flow, and proton pump inhibitors to prevent gastric acid production. Surgical interventions may include bile diversion surgery, in which a connection for bile drainage is made further down in the intestine, and anti-reflux surgery, in which the part of the stomach closest to the esophagus is gathered, wrapped, and then attached around the lower esophageal sphincter.
Copyright © 2011 Natural Standard (www.naturalstandard.com)
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.