RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE

ANNEXURE-II

APPLICATION FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THECANDIDATE AND ADDRESS / DR LETHA K ROBIN
DEPARTMENT OF MEDICINE FR.MULLER HOMOEOPATHIC MEDICAL COLLEGE AND HOSPITAL, UNIVERSITY ROAD, DERALAKATTE, MANGALORE-574160 KARNATAKA
PERMANENT ADDRESS / PROVINCIAL SUPERIOR, ST.JOSEPH PROVINCIALATE, DHARMAGIRI KOTHAMANGALAM, ERNAKULAM KERALA -686691
2. / NAME OF THE INSTITUTION / FATHER MULLER HOMOEOPATHIC MEDICAL COLLEGE AND HOSPITAL, DERALAKETTE,MANGALORE- 574160
3. / COURSE OF THE STUDY & SUBJECT / M.D. (HOM.)
PRACTICE OF MEDICINE
4. / DATE OF ADMISSION TO THE COURSE / 18- 06 -2007
5. / TITLE OF THE TOPIC
“APD -THE IMPORTANCE OF LIFE EVENTS IN THE DEVELOPMENT OF CLINICAL MANIFESTATIONS AND THEIR HOMOEOPATHIC MANAGEMENT”.
6. / BRIEF RESUME OF THE INTENDED WORK
6.1 Need for the study
Acid Peptic Disease (APD) bothers mankind from time immemorial. From crude non processed medicines to today’s most modern highly technical surgery could not offer much to this menace. More and more individuals are experiencing the difficulty of APD. APD is one of the commonest diseases, found in clinical practice. The reason may be the tight and busy schedule of modern life. This made me to think of a study based on this.
APD is a common disorder that affects millions of individuals in the United States each year. APD has a major impact on our health care system in accounting for roughly 10% of medical costs for digestive diseases. In US, one year point prevalence is 18%.APD affects 4.5 million people annually in US. The frequency of APD in others countries is variable. My study focus on APD because of its threat to society. The experience confirms that what antacids, proton pump inhibitors and highly selective vagotomies could not do, homoeopathic treatment has been doing effectively.
APD is one of the treatable entities and completely cured by effective treatment. Scope of homoeopathy in the management of APD is more efficient & effective. By homoeopathic treatment not only disease sy mptoms disappear but also it improves the quality of life.
So to prove that homoeopathy can manage to treat and also improve the quality of life of patients suffering from Acid Peptic Disease, it is necessary to use standard measuring instrument. The measuring instrument used in this study is recommended by the WHO. The instrument is called the World Health Organization Quality Of Life (WHO QOL) instruments. The instrument is used to measure change in quality of life during the course of treatment.
6.2 Review of literature
Acid peptic disease (APD) includes Gastritis, Gastro esophageal Reflux Disease (GERD), Peptic Ulcer and Zollinger – Ellinson Syndrome. This disease mainly provides an enriched psycho somatic relation ship. Emotions precipitate and modify this disease. Progress of the disease is directly proportional to the stress under which the patient is in and the environment in which the patient lives.
GASTRITIS
Classification of gastritis :
1. Acute gastritis: a) Acute H. Pylori infection .b) Other acute infectious gastritis: bacterial, viral, mycobacterial, phlegmonous, parasitic, fungal, and syphilitic.
2. Chronic gastritis: a) Type A: Autoimmune body predominant. b) Type B: H. Pylori related, antral predominant. C) Indeterminant.
3. Uncommon forms of gastritis: Lymphocytic, Eosinophilic, Granulomatous, Stress gastritis, Hypertrophic gastritis. 1
The most common symptoms are abdominal upset or pain. Other symptoms are belching, abdominal bloating, nausea, and vomiting or a feeling of fullness or of burning in the upper abdomen. Blood in your vomit or black stools may be a sign of bleeding in the stomach, which may indicate a serious problem requiring immediate medical attention.
Causes of Gastritis :

1. Irregular or excessive eating

The most frequent cause of gastritis is a dietetic indiscretion such as habitual overeating; eating of badly combined or improperly cooked foods; excessive intake

of strong tea, coffee, or alcoholic drinks; or habitual use of large quantities of condiments and sauces.

2. Worry, Anxiety

Other causes include worry, anxiety, grief, and prolonged tension, use of certain drugs, strong acids, and caustic substances. 2
Gastritis is diagnosed through one or more medical tests:
·  Upper gastrointestinal endoscopy.
·  Blood test.
·  Stool test : This test checks for the presence of blood in your stool, a sign of bleeding. Stool test may also be used to detect the presence of H. pylori in the digestive tract.
GASTRO ESOPHAGEAL REFLUX DISEASE (GERD)
GERD is a clinical condition when gastric juices, containing acid, travel back from the stomach into the gullet (the swallowing pipe called the esophagus) cause troublesome symptoms or complications.3 Psychological distress increases symptom severity in those prone to GERD. Excessive stress, too much excitement, family argument, temporary depression were believed to trigger heartburn.4
Symptoms :
Burning produced by bending, stooping or lying down. Pain precipitated by drinking hot liquids or alcohol and relieved by antacids. Eructation and dyspepsia are other symptoms.5
Diagnosis :
a)  In majority of cases diagnosis is assumed rather than proven.
b)  Endoscopy to exclude more serious pathology such as cancer.
c)  Barium swallow and meal examination
d)  24 hour PH monitoring is the gold standard for diagnosis of GERD. 6
Consequences of severe GERD are bleeding, stricture formation and Barett esophagus with pre disposition to malingnancy.7
Management :
Management includes weight reduction, sleeping with head elevated and elimination of factors that increase abdominal pressure. Patients should avoid fatty food, coffee ,alcohol and avoid smoking.1
PEPTIC ULCER
An ulcer that develop in the area of GI tract exposed to acid gastric juice are called peptic ulcers.8
No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum.
Ulcers can be caused by:
·  Infection with a type of bacteria called Helicobacter pylori (H. pylori)
·  Use of painkillers called nonsteroidal anti-inflammatory drugs.
Symptoms:
·  A gnawing or burning pain in the middle or upper stomach between meals or at night
· 
·  Bloating
·  Heartburn
·  Nausea and vomitting
In severe cases, symptoms can include:
- Dark or black stool (due to bleeding)
- Vomiting blood (can have a “coffee-grounds” apearance)
·  - Psychological stress has been thought to contribute to PUD
· 
·  PUD is associated with certain personality traits. Studies of prisoners of World War II,documented rates of peptic ulcer formation twice as high as controls.The role of H.pylori in peptic ulceration suggest that psychological factors play primarily a role in the clinical expression of symptoms. Stressful life events reduce immune responses resulting in a higher vulnerability to infection with H.pylori.4
Investigations :
1.Examination of blood : Hb will be low due to chronic blood loss.
2.Examination of stool : Occult blood detectable in all cases of active ulcer.
3. Gastric function tests .
4. Radiological examination – Barium meal x-ray is diagnostic in peptic ulcer.
5. Endoscopy has felicitated diagnosis of PUD.9
Complications include haemorrhage ,perforation ,gastric outlet obstruction.5
Management :
Rest as far as practicable.Anxiety & elements of stress and strain should be avoided. Diets should be regulated and must be taken in time. Alcohol and smoking to be prohibited.9
ZOLLINGER – ELLISON SYNDROME(GASTRINOMA)
This is a rare disorder where severe peptic ulceration occurs due to benign adenoma or a malignant tumor or hyper plasia of D cells of Islets of pancreas. Diagnosis by measuring serum gastrin.10
PSYCHOSOMATIC ASPECTS OF APD
Physical symptoms are the manifestation of underlying psychological distress disease. As a general outline people prove to develop CVS and GI problems (APD) were found to lead a competitive achievement oriented life style and were marked by hurry, impatience nervousness and frustration. Responses to stressful events have three components : an emotional response , physical response and psychological response.11
Emotional changes in human beings were accompanied by physiological changes and when emotional changes were frequent, pathological physical changes would follow. Among psycho somatic disorders APD is very common.
Gastro intestinal symptoms are often an expression of stressful life. Poor appetite, abdominal pain, indigestion etc.are results of anxiety. GI disorders rank high in medical illnesses associated with stressful life events.4
QUALITY OF LIFE :
It is a general term applied to the totality of physical, psychological and social functioning. It is determined by physical impairment, emotional reaction, personality, illness behavior and sick role. Illness usually impairs Quality of life. 11
In clinical practice the WHO Quality Of Life instrument may be used with other forms of assessment giving valuable information that can indicate areas in which a person is most affected and help the practitioners making the best choices in patient care. In addition, they may be used to measure change in Quality of life over a course of treatment. Based on these facets, questionnaire is framed and it will be distributed to the patient before and after treatment. By assessing the improvement in the quality of life of the patient, the efficacy of Homoeopathic treatment is judged.
HOMOEOPATHIC APPROACH
Dr. Hahnemann considered disease as a state indicating disharmonious functioning of life force. We become aware of this disharmony by the loss of that sense of well being. As disharmony progress, more definite indications start appearing first in the form of symptoms followed by signs. The natural tendency of life force is to restore the state of harmony. The physician is expected to promote this natural tendency.
In the study of disease, the Homoeopathic physician considers the individual response as of great importance from the standpoint of the selection of curative remedy and is guided by totality of symptoms. In aphorism 6, he states that “ all this perceptible signs represent the disease in its whole extent, that is together they form the true and only conceivable portrait of the disease”.12
In health all expressions of vital force may be expressed by perfect functioning of all parts of the body and a sense of general well being. In disease this expression is vastly changed. All the external forces , when in conjunction with already disturbed vital force , have very profound effects upon the vital functions and they are manifested in a trail of symptoms which are expressed in different ways in varying individuals.13
Homoeopathic remedies are prescribed by symptoms rather than conditions, as each case of particular illness can manifest differently in different people.
The sickness of the person expresses itself at his various levels, and to bring all such expressions together to get a whole picture, requires a clear understanding of what Hahnemann stated: “ what is to be cured in a disease, that is to say in every individual case of disease.’’14
6.3 Objectives of the study
1. To find out the life events which lead to the development of APD.
2. The impact of Homoeopathic treatment in improving the quality of life of
patients with APD
7. / MATERIALS & METHODS
7.1 Source of data The subjects will be selected from OPD, IPD and peripheral centers of Fr.Muller Homoeopathic Medical College and Hospital, Mangalore.
About 100 cases will be taken out of which of 30 cases will be selected using purposive sampling technique based on the inclusion criteria and will be followed for a minimum period of 6months to 1year.
7.2.Method of collection of data
The Materials and Methods used for the Study :
The subjects will be selected by purposive sampling method and processed in a standardized case record. The Quality of life of patients will be analyzed using WHO Quality Of Life-BREF tool before and after Homoeopathic treatment.
Every case will be analyzed and reference from materia medica and repertory will be taken whenever required.
Each case will be evaluated according to the scoring criteria which includes the Intensity of symptoms before and after treatment.
Inclusion Criteria
* People of age group 25 to 60 years, both sex.
* Diagnostic criteria mainly based on clinical history & clinical examination.
Exclusion Criteria.
·  Ulcers secondary to burns, uremia and drugs are not considered.
·  Cases complicated with hemorrhage, perforation and gastric outlet obstruction are not considered.
Research hypothesis :
Homoeopathic treatment is effective in improving the quality of life of patients with APD.
Null hypothesis :
There is no significant difference between pre and post treatment score.
Research design
Experimental design: Before and after homoeopathic treatment without control.
Plan For Data analysis
Collected data will be analyzed by‘t’ test. Data will be presented in the form of Mean, Standard deviation, Frequency, Percentage and Diagrams.
7.3 Does the study require any investigation to be conducted on patients or other humans?
Endoscopy may be required in some cases to rule out other clinical conditions.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes enclosed.
8. / LIST OF REFERENCES
1. Kasper D.L., Braunwald, Fauci A.S., Hauser, Longo, Jameson. Harrison’s principles of international medicine. 16thed. New York: Mc Graw Hill; 2005.p.1760.
2. Wikipedia, the free encyclopedia. URL: http://www/.en. Wikipedia./ Org wiki/ gastritis.
3. Patient health international. http://www./. en.wikipedia/org wiki/ gastro esophageal reflux disease.
4. Sadock Benjamin, Sadock Virginia. Kaplan & Sadock’s comprehensive text book of psychiatry. 8th ed. U.S.A: William& Wilkins; 2005.p.2112-18.
5. Kumar Praveen & Clark Michael. Clinical medicine. 6th ed. U.S.A: Elsevier Saunder’s Publication; 2005.p.275.
6. Russel R.C.G, William Norman, Bulstrode Christopher. Bailey & Love’s short practice of surgery. 24th ed. New York: Edward Arnold; 2004.p.1000.
7. Kumar Vinay, Cotran Ramzi S, Robbins Stanley L. Basic pathology. 7th ed. Bangalore: W.B. Saunder’s & Company; 2003.p.552.
8. Tortora Gerard J, Derrickson Bryan. Principles of anatomy and physiology. 11th ed. U.S.A: John Wiley & Sons; 2006.p.942.
9. Das Somen. A concise text book of surgery. 3rd ed. Dr. Das Calcutta; 2001.p.823-25.
10. Boon Nicholas, Colledge Nicki R, Walker Brian, Hunter John. Davidson’s principles & practice of medicine. 20th ed. U.S.A: Churchill Livingstone; 2006.p.890.
11. Gelder Michael, Gath Dennis. Oxford text book of psychiatry. 3rd ed. U.S.A: Oxford University Press; 1996.p.134-38.
12. Hahnemann Samuel. Organon of medicine.6th ed. New Delhi: B. Jain Publishers; 1998.p.93-94.
13. Robert H.A. The principles and art of cure. Reprint ed. New Delhi:B.Jain Publishers; 1999.p.42.
14. Tiwari S K. Essentials of repertorisation. 4th ed. New Delhi: B. Jain Publishers; 2005.p.38.
9. / SIGNATURE OF THE CANDITATE
10. / REMARKS OF THE GUIDE
11. / 11.1 NAME & DESIGNATION
OF THE GUIDE / DR M.K.KAMATH, M.D (HOM), PROFESSOR, DEPT. OF MEDICINE, FATHER MULLER HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL, DERALAKATTE, MANGALORE.
11.2 SIGNATURE
11.3 CO – GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT / DR M.K.KAMATH M.D(HOM), PROFESSOR, DEPT. OF MEDICINE, FATHER MULLER HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL, DERALAKATTE, MANGALORE.
11.6 SIGNATURE
12. / 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL.
12.2 SIGNATURE

1