Understanding Esophageal Cancer: A Comprehensive Guide
Introduction
Esophageal cancer, a disease with a history as old as medicine itself, remains a significant health challenge worldwide. This form of cancer arises in the esophagus, the tube that carries food from the mouth to the stomach. Over the centuries, medical understanding of esophageal cancer has evolved substantially, and today, we have a deep understanding of its causes, risk factors, and the progression of the disease. This article aims to provide an accessible yet comprehensive guide to understanding esophageal cancer, from its definition to its potential risk factors. Esophageal cancer is a type of cancer that originates in the cells lining the esophagus.
Description of Esophageal Cancer
Esophageal cancer is a disease that occurs when cells in the esophagus start to grow uncontrollably. These cells can invade nearby tissues and spread to other parts of the body, a process known as metastasis. The progression of esophageal cancer can be gradual and is often asymptomatic in its early stages, which can make it challenging to detect.
There are two main types of esophageal cancer: squamous cell carcinoma, which starts in the flat cells lining the esophagus, and adenocarcinoma, which begins in cells that make and release mucus and other fluids. The prevalence of these types varies worldwide, with squamous cell carcinoma more common globally, while adenocarcinoma is more prevalent in the United States.
According to the American Cancer Society, esophageal cancer represents about 1% of all cancers diagnosed in the United States, but it is significantly more common in other parts of the world, like certain areas of Asia and Africa. It’s estimated that in 2023, about 18,440 new esophageal cancer cases will be diagnosed in the United States, and about 15,820 people will die from this disease.
Risk Factors for Developing Esophageal Cancer
Lifestyle Risk Factors
A number of lifestyle-related factors have been linked to an increased risk of developing esophageal cancer. These include tobacco use, heavy alcohol consumption, and a diet low in fruits and vegetables. Obesity is also a significant risk factor, particularly for adenocarcinoma of the esophagus. Chronic gastroesophageal reflux disease (GERD), in which stomach acid regularly backs up into the esophagus, can also increase risk, particularly if it leads to a condition called Barrett’s esophagus.
Medical Risk Factors
Medical conditions can also contribute to the risk of esophageal cancer. As mentioned, Barrett’s esophagus, a complication of GERD, increases the risk of adenocarcinoma. Other medical risk factors include achalasia (a condition affecting esophageal muscle contractions), tylosis (a rare, inherited disorder), and certain head and neck cancers. Previous radiotherapy treatment to the chest or upper abdomen can also increase the risk.
Genetic and Age-Related Risk Factors
Genetic factors can play a part in esophageal cancer risk. Individuals with certain inherited genetic syndromes, such as Lynch syndrome or Fanconi anemia, are at a higher risk. Age also plays a significant role in esophageal cancer risk. Although it can occur at any age, esophageal cancer is more common in people over the age of 55. The median age at diagnosis is 68 years. Additionally, men are more likely to develop
Clinical Manifestations
Difficulty Swallowing (Dysphagia)
This symptom occurs in up to 50% of people with esophageal cancer, often as one of the earliest signs of the disease. Dysphagia is a condition where swallowing becomes difficult or uncomfortable. In esophageal cancer, a tumor may grow and narrow the esophagus, making it harder for food and liquids to pass into the stomach.
Unintentional Weight Loss
Approximately 60-70% of people with esophageal cancer experience unintentional weight loss. This often results from dysphagia, which can limit food intake, and from the cancer itself, which can change the way the body uses calories.
Chest Pain or Discomfort
About 40-70% of esophageal cancer patients report chest pain or discomfort. This occurs when the cancer invades the outer layers of the esophagus or nearby structures. The pain may feel like heartburn or indigestion and can increase with swallowing.
Chronic Cough
While less common, a chronic cough can occur in about 10-20% of cases. This can result from the tumor irritating the trachea, or windpipe, especially if the cancer is near the top of the esophagus.
Hoarseness
Hoarseness occurs in roughly 10% of cases. If the cancer spreads to the laryngeal nerves, it can paralyze the vocal cords and change the sound of the voice.
Frequent Hiccups
Although relatively rare, frequent hiccups can occur in esophageal cancer. They can result from the tumor irritating the diaphragm, the muscle that separates the chest from the abdomen.
Regurgitation of Food or Liquids
Regurgitation of food or liquids can happen if the tumor narrows the esophagus, preventing food and liquids from passing into the stomach. About 10-15% of patients with esophageal cancer may experience this symptom.
Pain or Burning Sensation in the Throat or Chest
This symptom can occur in up to 40% of people with esophageal cancer, especially if the cancer is in the lower part of the esophagus. It can feel similar to severe heartburn or gastroesophageal reflux disease (GERD).
Fatigue
Fatigue is common in about 80% of people with any type of cancer, including esophageal cancer. It can result from the cancer itself or from the body’s response to the cancer.
Persistent Indigestion or Heartburn
About 50% of people with esophageal cancer have persistent indigestion or heartburn. This can occur when the tumor irritates the lining of the esophagus, causing discomfort or a burning sensation in the chest or throat.
Diagnostic Evaluation
The diagnosis of esophageal cancer involves a detailed medical history, a physical examination, and a series of tests. The goal is to identify the presence of a tumor in the esophagus and determine if it has spread to nearby tissues or distant organs. This process is essential for planning the most effective treatment strategy.
Upper Endoscopy (EGD)
An upper endoscopy, also known as an esophagogastroduodenoscopy (EGD), is a common initial test for diagnosing esophageal cancer. During this procedure, a flexible tube with a camera at the end (endoscope) is passed down the throat to examine the esophagus, stomach, and the first part of the small intestine. This allows the doctor to visually detect any abnormalities. EGD is essential because it can locate a tumor and determine its size and location.
If esophageal cancer is suspected, the doctor may take a biopsy during the endoscopy to be examined under a microscope. Abnormal cells, including cancerous and precancerous cells, can confirm a diagnosis of esophageal cancer.
Endoscopic Ultrasound (EUS)
Endoscopic ultrasound is another crucial tool in diagnosing esophageal cancer. It involves using an endoscope equipped with an ultrasound probe. The probe sends out sound waves that bounce off tissues and create an image of the esophagus wall and surrounding tissues. This can help assess the depth of tumor invasion and whether nearby lymph nodes are involved. The doctor may also use EUS to guide a needle into a lymph node or suspicious area to take a biopsy.
A finding of a thickened esophageal wall or enlarged lymph nodes may suggest esophageal cancer. If the test is negative but symptoms persist, further investigation is warranted.
Barium Swallow
A barium swallow, or esophagram, involves swallowing a liquid that contains barium, which coats the esophagus and makes it show up more clearly on X-rays. This can help identify tumors or other abnormalities.
On a barium swallow, esophageal cancer may appear as a narrowing or irregularity of the esophagus. However, small or early-stage cancers may not be seen with this test, so a negative result does not definitively rule out esophageal cancer.
Esophageal Manometry
Esophageal manometry is a test that measures the pressure and coordination of muscle contractions in the esophagus. While not typically used to diagnose esophageal cancer, it can help determine the cause of esophageal symptoms and rule out other conditions.
If this test is performed and the results are negative, but symptoms continue, further testing may be needed to identify the cause.
Esophageal pH Monitoring
Esophageal pH monitoring measures the amount of stomach acid that enters the lower part of the esophagus. This test is not used to diagnose esophageal cancer, but it can help identify GERD, which is a risk factor for esophageal adenocarcinoma.
If the test results do not show acid reflux but symptoms persist, further investigation may be necessary.
CT Scan
A computed tomography (CT) scan uses X-rays to create detailed cross-sectional images of the body. It can help determine the size, shape, and location of a tumor, and whether the cancer has spread to nearby lymph nodes or other parts of the body.
On a CT scan, esophageal cancer may appear as a thickening or mass in the esophagus. If the CT scan does not show a tumor but symptoms continue, other tests may be needed.
PET Scan
A positron emission tomography (PET) scan can help determine if esophageal cancer has spread to lymph nodes or other parts of the body. It involves injecting a small amount of a radioactive sugar substance, which cancer cells absorb more than normal cells. The scanner then detects the radiation.
A PET scan can identify areas of cancer that may not be seen with other imaging tests. However, not all insurance companies cover PET scans for esophageal cancer, and they are not always necessary.
MRI
Magnetic resonance imaging (MRI) uses powerful magnets and radio waves to create detailed images of the body. While not typically the first choice for evaluating esophageal cancer, it can be used in certain situations, such as evaluating the extent of the tumor or determining if the cancer has spread to the liver.
If the MRI does not show a tumor but symptoms persist, other tests may be needed.
Blood Tests
While there are no specific blood tests to diagnose esophageal cancer, general blood tests can assess a patient’s overall health, evaluate organ function, and look for signs of cancer spreading.
Blood tests can show changes in the body’s function, but they cannot definitively diagnose esophageal cancer. If blood tests are normal but symptoms continue, further investigation may be necessary.
If all tests are negative but symptoms persist, it’s important to discuss this with your doctor. They may recommend further testing or refer you to a specialist. Remember, it’s crucial to advocate for your health. Persistent symptoms deserve attention and evaluation.
Health Conditions with Similar Symptoms to Esophageal Cancer
Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease, commonly known as GERD, is a chronic condition where stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus and cause symptoms such as heartburn and regurgitation of acid.
GERD and esophageal cancer share symptoms like heartburn, chest pain, and difficulty swallowing. However, GERD is usually associated with a sour taste in the mouth, belching, and a burning sensation in the chest, which do not typically occur with esophageal cancer. On the other hand, weight loss and painful swallowing are more associated with esophageal cancer. Tests such as an endoscopy or a pH monitoring test can help differentiate between GERD and esophageal cancer. A normal endoscopy and abnormal pH monitoring test would suggest GERD, while an abnormal endoscopy would raise suspicion for esophageal cancer.
Esophagitis
Esophagitis refers to inflammation of the esophagus that can lead to tissue damage if left untreated. It can be caused by various conditions, including GERD, infections, certain medications, and allergies.
Both esophagitis and esophageal cancer may cause symptoms such as pain when swallowing and heartburn. However, esophagitis can also cause symptoms like a sore throat and a feeling of something stuck in the throat, which are less common with esophageal cancer. An endoscopy showing inflammation of the esophagus without a mass would suggest esophagitis, while the presence of a mass would raise suspicion for esophageal cancer.
Achalasia
Achalasia is a rare disorder that makes it difficult for food and liquid to pass into your stomach. It occurs when nerves in the esophagus become damaged, leading to difficulties with swallowing and often causing food to come back up into the throat.
While both achalasia and esophageal cancer can cause difficulty swallowing and regurgitation of food, chest pain after eating and a sensation of food being stuck in the chest area are more common in achalasia. A specific type of X-ray called a barium swallow and esophageal manometry can help distinguish between these two conditions. Abnormal results on these tests without the presence of a mass would suggest achalasia.
Esophageal Stricture
An esophageal stricture is a narrowing of the esophagus which can lead to swallowing difficulties. It’s often caused by damage to the esophagus from stomach acid in people with GERD.
Esophageal cancer and esophageal stricture can both cause difficulty swallowing and weight loss. However, a sudden onset of these symptoms might suggest a stricture. An endoscopy or barium swallow showing a narrowing of the esophagus without a mass would suggest an esophageal stricture.
Benign Tumors of the Esophagus
Benign tumors of the esophagus are noncancerous growths that can occur in various layers of the esophagus. While they are not life-threatening on their own, they may cause discomfort and difficulty swallowing.
Both benign esophageal tumors and esophageal cancer can cause difficulty swallowing and chest pain. However, benign tumors often grow slowly and symptoms may not be as severe as those associated with esophageal cancer. An endoscopy, biopsy, or imaging tests showing a mass without signs of malignancy would suggest a benign tumor.
Hiatal Hernia
A hiatal hernia occurs when the upper part of your stomach bulges through the large muscle (diaphragm) that separates your abdomen from your chest. This condition can cause acid reflux and heartburn.
Hiatal hernia and esophageal cancer share symptoms such as heartburn, chest pain, and difficulty swallowing. However, hiatal hernia may also cause belching and a feeling of fullness after eating, which are less common in esophageal cancer. Imaging tests like a barium swallow or an upper endoscopy can help differentiate between the two conditions. A hiatal hernia would appear as a protrusion of the stomach through the diaphragm, while esophageal cancer would present as a mass in the esophagus.
Eosinophilic Esophagitis
Eosinophilic esophagitis (EoE) is a chronic immune system disease in which a type of white blood cell (eosinophil) builds up in the lining of the esophagus. This buildup can lead to inflammation and difficulty swallowing.
Both EoE and esophageal cancer can cause difficulty swallowing and chest pain. However, EoE is often associated with food allergies and may also cause symptoms like nausea and vomiting, which are less common in esophageal cancer. An endoscopy and biopsy showing eosinophils in the esophagus without a mass would suggest EoE.
Gastrointestinal Bleeding
Gastrointestinal bleeding refers to any bleeding that occurs in the digestive tract, which includes the esophagus. Bleeding can be caused by various conditions, including ulcers, inflammation, or tumors.
Both esophageal cancer and gastrointestinal bleeding can cause vomiting blood or passing dark, tarry stools. However, gastrointestinal bleeding can also cause symptoms like dizziness, weakness, and shortness of breath, which are less common in esophageal cancer. Tests such as an endoscopy, colonoscopy, or imaging studies can help identify the source of the bleeding and differentiate between the two conditions.
Gastric Cancer
Gastric cancer, or stomach cancer, occurs when cancer cells form in the lining of the stomach. It is often detected at later stages due to a lack of early symptoms.
Gastric cancer and esophageal cancer can both cause symptoms like unintentional weight loss, difficulty swallowing, and indigestion. However, gastric cancer may also cause symptoms like abdominal pain, bloating, and loss of appetite, which are less common in esophageal cancer. An endoscopy, biopsy, or imaging tests can help distinguish between gastric and esophageal cancer.
Lung Cancer
Lung cancer is a type of cancer that begins in the lungs. It is the leading cause of cancer death worldwide. Lung cancer can cause various symptoms, some of which may overlap with esophageal cancer.
Both lung cancer and esophageal cancer can cause symptoms like chest pain, hoarseness, and chronic cough. However, lung cancer may also cause symptoms like shortness of breath, wheezing, and coughing up blood, which are less common in esophageal cancer. Imaging tests such as a chest X-ray, CT scan, or PET scan can help distinguish between lung and esophageal cancer.
Treatment Options
Chemotherapy Drugs
Chemotherapy drugs are powerful medications used to kill cancer cells. They work by preventing cancer cells from growing and dividing, thus slowing or stopping the growth of cancer.
Chemotherapy is often used as a first-line treatment for esophageal cancer, especially when the disease is advanced or has spread to other parts of the body. It may also be used before or after surgery to shrink tumors or kill remaining cancer cells.
Patients can expect to see a decrease in the size of their tumors and a potential improvement in symptoms after chemotherapy. However, the effectiveness can vary depending on the stage and type of the cancer.
Radiation Therapy Medications
Radiation therapy uses high-energy rays to kill cancer cells. It can be delivered externally by a machine that directs the rays at your cancer, or internally through radioactive substances placed inside your body.
Radiation therapy may be used in combination with chemotherapy as a primary treatment, before surgery to shrink a tumor, or after surgery to kill any remaining cancer cells. It may also be used to relieve symptoms of esophageal cancer such as pain or difficulty swallowing.
The effectiveness of radiation therapy varies, but it can often shrink tumors and alleviate symptoms, improving the quality of life for esophageal cancer patients.
Pain Relievers
Pain relievers, or analgesics, are drugs used to relieve pain. They range from over-the-counter options like acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) to prescription drugs like opioids.
Pain relievers can be used at any stage of esophageal cancer to help manage pain associated with the disease or its treatment. The choice of pain reliever will depend on the severity of the pain.
While pain relievers do not treat the cancer itself, they can significantly improve the quality of life for patients by reducing pain and discomfort.
Antiemetics
Antiemetics are medications that help prevent and treat nausea and vomiting, common side effects of chemotherapy and radiation therapy.
Antiemetics are typically used when patients undergo chemotherapy or radiation therapy, which can cause nausea and vomiting. They may also be used if the cancer causes ongoing nausea.
These medications can effectively manage and prevent nausea and vomiting, improving the patient’s ability to eat and drink and overall quality of life.
Proton Pump Inhibitors (PPIs)
Proton pump inhibitors (PPIs) are a type of medication that reduces the production of stomach acid. They are often used to treat acid reflux symptoms in esophageal cancer patients.
PPIs may be used throughout the treatment process to manage symptoms of heartburn and acid reflux, which are common in esophageal cancer patients.
By reducing stomach acid, PPIs can help alleviate heartburn and acid reflux symptoms, improving the patient’s comfort and ability to eat.
Acid Suppressors
Acid suppressors, including H2 blockers and antacids, work to reduce the amount of acid in the stomach, which can help alleviate heartburn and acid reflux symptoms.
Like PPIs, acid suppressors can be used throughout the treatment process to manage symptoms of heartburn and acid reflux in esophageal cancer patients.
By reducing stomach acid, acid suppressors can help relieve heartburn and acid reflux symptoms, improving the patient’s comfort and ability to eat.
Antibiotics (if infection is present)
Antibiotics are medications used to treat bacterial infections. If an esophageal cancer patient develops an infection, antibiotics may be prescribed.
Antibiotics are used when needed to treat bacterial infections in esophageal cancer patients, such as pneumonia or a skin infection at a surgical site.
By treating the infection, antibiotics can help the patient recover more quickly and prevent complications from the infection.
Immunotherapy Drugs
Immunotherapy drugs are a type of cancer treatment that helps your immune system fight cancer. They work by helping the immune system recognize and attack cancer cells.
Immunotherapy may be used in certain cases of advanced or metastatic esophageal cancer, especially when the cancer has not responded to other treatments.
Immunotherapy can sometimes help shrink tumors and slow the progression of the disease. However, not all patients respond to immunotherapy, and it can cause side effects like fatigue, nausea, and skin reactions.
Targeted Therapy Drugs
Targeted therapy drugs are designed to target specific characteristics of cancer cells, such as a protein that allows the cancer cells to grow in a rapid or abnormal way. They work differently from standard chemotherapy drugs.
Targeted therapy may be used in certain cases of advanced esophageal cancer, especially when the cancer has certain genetic or molecular features.
Targeted therapies can help shrink tumors and slow disease progression. However, as with other treatments, not all patients respond to targeted therapy, and it can cause side effects such as skin problems, high blood pressure, and fatigue.
Supportive Care Medications
Supportive care medications are used to manage the symptoms and side effects of esophageal cancer and its treatment. They can include pain relievers, antiemetics, and medications to prevent constipation or other digestive issues.
Supportive care medications are used throughout the treatment process to help manage symptoms and side effects and improve the patient’s quality of life.
These medications can significantly improve comfort and quality of life for patients undergoing treatment for esophageal cancer.
Surgery (Esophagectomy)
An esophagectomy is a surgical procedure to remove part or all of the esophagus. The remaining esophagus is then reconnected to the stomach, sometimes with a piece of the patient’s intestine used as a bridge.
Esophagectomy is typically used when esophageal cancer is found in the early stages and the tumor is localized. It may also be used after chemotherapy or radiation therapy to remove any remaining cancer.
Esophagectomy can potentially cure esophageal cancer if the disease is localized. However, it is a major surgery with significant risks and recovery time.
Chemotherapy
Chemotherapy, as a procedure, involves the administration of drugs that kill or inhibit the growth of cancer cells. It can be administered intravenously, orally, or through a targeted method.
Chemotherapy is often used as a primary treatment for esophageal cancer, particularly in advanced stages. It may also be used before surgery to shrink tumors or after surgery to kill any remaining cancer cells.
Chemotherapy can shrink tumors, slow disease progression, and relieve symptoms. The effectiveness can vary depending on the stage and type of the cancer.
Radiation Therapy
Radiation therapy, as a procedure, involves the use of high-energy rays to kill cancer cells. The radiation can be targeted directly at the tumor to minimize damage to healthy cells.
Radiation therapy can be used as a primary treatment, often in combination with chemotherapy, or it may be used before surgery to shrink tumors or after surgery to kill remaining cancer cells.
Radiation therapy can shrink tumors, slow the progression of the disease, and relieve symptoms such as pain or difficulty swallowing.
Endoscopic Mucosal Resection (EMR)
Endoscopic mucosal resection (EMR) is a procedure used to remove early-stage cancer and precancerous tissues from the lining of the digestive tract.
EMR is typically used in the early stages of esophageal cancer, when the cancer is still limited to the surface layers of the esophagus and has not spread to deeper layers or other areas.
EMR can potentially cure early-stage esophageal cancer and precancerous conditions of the esophagus.
Photodynamic Therapy
Photodynamic therapy (PDT) is a treatment that uses a drug, called a photosensitizer, and a particular type of light to kill cancer cells.
PDT is typically used for early-stage esophageal cancer or for high-grade dysplasia (precancerous cells) in Barrett’s esophagus.
PDT can potentially cure early-stage esophageal cancer and precancerous conditions. It can also relieve symptoms in more advanced cases.
Radiofrequency Ablation
Radiofrequency ablation uses heat generated by radio waves to kill cancer cells. It is usually done during an endoscopy.
Radiofrequency ablation is used mainly to treat Barrett’s esophagus, a condition that can lead to esophageal cancer, by destroying the abnormal cells.
Radiofrequency ablation can potentially cure Barrett’s esophagus and prevent the development of esophageal cancer.
Esophageal Stent Placement
An esophageal stent is a tube placed inside the esophagus to keep it open and allow the patient to swallow. This is often done when a tumor is blocking the esophagus.
Stent placement is typically used in advanced esophageal cancer to alleviate symptoms and improve quality of life.
Stent placement can effectively relieve symptoms like difficulty swallowing, helping patients eat and drink more comfortably.
Laser Therapy
Laser therapy uses high-intensity light to kill cancer cells. The laser is typically guided by an endoscope inserted through the mouth and into the esophagus.
Laser therapy is often used to relieve symptoms in advanced esophageal cancer, such as a tumor blocking the esophagus.
Laser therapy can effectively shrink tumors and relieve symptoms like difficulty swallowing.
Palliative Procedures (to relieve symptoms)
Palliative procedures are treatments aimed at relieving symptoms and improving quality of life, rather than curing the cancer. They can include procedures to remove or shrink the tumor, manage pain, or address other symptoms.
Palliative procedures are used when esophageal cancer is advanced and cannot be cured. The goal is to improve the patient’s quality of life and comfort level.
Palliative procedures can effectively relieve symptoms, reduce pain, and improve quality of life for patients with advanced esophageal cancer.
Targeted Therapy
Targeted therapy, as a procedure, involves the administration of drugs that target specific characteristics of cancer cells, helping to stop their growth and spread.
Targeted therapy may be used in certain cases of advanced esophageal cancer, especially when the cancer has certain genetic or molecular features.
Targeted therapies can help shrink tumors and slow disease progression. However, not all patients respond to targeted therapy, and it can cause side effects such as skin problems, high blood pressure, and fatigue.
Improving Esophageal Cancer and Seeking Medical Help
There are several home remedies and lifestyle changes that can help manage the symptoms of esophageal cancer and improve your quality of life. These include nutritional support such as a liquid or soft diet, eating smaller, more frequent meals, and ensuring adequate hydration. Smoking cessation and moderation of alcohol intake are crucial as both can exacerbate the condition. Stress management techniques, weight management, and gentle exercise can also play an essential role in improving overall health and well-being.
Palliative care support is crucial in the management of esophageal cancer, especially in advanced stages. Emotional and psychological support, either through professional counseling or support groups, is equally important for mental health.
Remember, while these measures can help, they do not replace professional medical treatment. If you notice persistent symptoms or if your symptoms worsen, it’s essential to seek immediate medical help. Telemedicine services, such as ours, make it convenient and safe for you to access quality healthcare from the comfort of your home.
Living with Esophageal Cancer: Tips for Better Quality of Life
Living with esophageal cancer requires adjustment and resilience. Alongside medical treatment, maintaining a healthy lifestyle, a strong support network, and a positive mindset can go a long way in improving your quality of life.
Conclusion
Esophageal cancer is a serious condition that requires early diagnosis and treatment for the best possible outcomes. Understanding the signs, symptoms, diagnostic tests, treatments, and lifestyle modifications is crucial in managing this disease effectively.
Remember, early diagnosis significantly improves the success rate of treatment. So, do not hesitate to seek medical help if you notice any persistent or worsening symptoms. Our primary care telemedicine practice is here to assist you, providing accessible, quality healthcare at your convenience.
Brief Legal Disclaimer: This article is for informational purposes only and not intended as medical advice. Always consult a healthcare professional for diagnosis and treatment. Reliance on the information provided here is at your own risk.