Dear Dr. Roach: For several years, when I have had blood drawn it has shown an elevation in the alkaline phosphatase. It has been as high as 377 in recent tests. I have had the test to see if it was from the liver, but it was all right. I recently had a bone scan, and the doctor suspects Paget鈥檚 disease and is referring me to a bone oncologist. Do you have any comments in regard to this? D.C.A.
Alkaline phosphatase is an enzyme that, when found in the blood, usually comes from the liver. Conditions such as gallstones or others that affect bile flow are the most likely to increase the level in the blood. However, alkaline phosphatase may also come from the bone, and in this case, Paget鈥檚 disease is the most likely cause. Your doctor may have determined where the alkaline phosphatase is coming from by ordering a special isoenzyme blood test. The bone scan is usually diagnostic for Paget鈥檚.
Paget鈥檚 disease is thought to result from abnormal osteoclasts, the cells that normally remodel bone. The osteoclasts break down bone, and osteoblasts build it back up again. Bone needs to be replaced over time to repair any microscopic cracks that may have formed. Without normal bone turnover, the bones become brittle.
In Paget鈥檚 disease, the bone remodelling in one or more particular areas is excessive, causing bone buildup. The most common sites are the skull, spine, pelvis and leg bones. Paget鈥檚 disease is very effectively treated with medications such as zoledronic acid (Reclast or Zometa). While not all people with Paget鈥檚 need treatment, a high alkaline phosphatase level usually is a reason to treat.
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Dear Dr. Roach: I am 77, female and in great health except for being diagnosed with achalasia. I know it is rare, and I was happy to find out why my digestive system had discomfort. Do yoga twists or shoulder stands worsen this? It seems worse when I do these. E.H.
Achalasia is a disease of abnormal movement in the esophagus, the muscular tube that carries food from the back of your throat to the stomach. It is caused by damage to the nerves in the esophagus, possibly from destruction by the body's immune system. Because of the nerve damage, the food gets stuck in the esophagus, leading to difficulty swallowing and vomiting of undigested food. Both solids and liquids are affected, as opposed to esophageal cancer, in which the problem is mostly solids.
Gravity helps us swallow, so being upside down will make gravity work against you, and I would expect the condition to worsen with yoga positions that turn the esophagus upside down. I wouldn鈥檛 recommend those types of positions, especially since they may cause or worsen vomiting.
Treatment of achalasia should be done by an expert in the condition, and may include dilation of the esophagus, injection with Botox into the muscle or surgery.
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Dear Dr. Roach: What is the difference between a CT scan and an MRI?
B.
A CT (computerized tomography) scan uses X-rays to create an image that looks like a slice through the body, head or a limb.
The quality of the picture is excellent, but it uses much more radiation than a regular X-ray. An MRI uses powerful magnetic waves to create an image that also looks like a slice. It uses no radiation. CT scans are cheaper and faster, in general. One isn鈥檛 necessarily better than the other. MRIs tend to be better for looking at soft tissues, like the brain, and CT usually is better for looking at bones. Your doctor, or the consulting radiologist, can tell you which is more likely to be better in your individual situation.
