Materia Medica Malaysiana

At the gut of the problem

IT has been “clinically” proven that bosses can be a real pain in the butt! A study conducted at Queen Elizabeth Hospital in Kota Kinabalu, Sabah, showed that this unflattering remark could have stemmed from real biological problems related to dealing with irritating authoritative figures.

After interviewing 402 patients with irritable bowel syndrome (IBS), Dr JHK Lee and his colleagues concluded that employees were more at risk of suffering from this medical condition. The majority of patients (66%) were employees, and 55% of them were between 35 and 54 years of age.

Dr Lee’s team also concluded that there was no significant association of the disease with socio-economic standard, educational background and ethnic origin.

The findings were documented in a paper titled “IBS in East Malaysia: Does socio-economic status make a difference?”, which is included in the June supplement edition of the Malaysia Medical Journal.

The findings were also presented at the four-day Gut 2004 annual scientific meeting organised recently by the Malaysian Society of Gastroenterology and Hepatology (MSGH) at Shangri-La’s Rasa Sayang Resort in Penang.

But pain in the butt could also be self-inflicted, said a group of researchers from Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur.

The group reported two cases where patients were rushed to the emergency unit with aerosol spray canisters “accidentally” lodged in their rectums.

Dr A. Kalyani said some individuals inserted foreign matter into their rectum, penis and vagina for sexual gratification, while some did it to satisfy a psychological perversion.

Apart from discussing the topic of aching butts, the meeting attended by 400 participants also covered the treatment and complications of various types of hepatitis, and cancers of the liver and gastrointestinal organs.

”Seventy-five per cent of the 350 million people chronically infected by the Hepatitis B virus are Asians,” said Health Ministry deputy director-general Datuk Dr Mohd Ismail Merican, who presented the inaugural Panir Chelvam Memorial Lecture.

The lecture is held in memory of the society’s founding member Dr Panir, who died of myocardial infarction in March.

“The outcome of treatment of hepatitis infection is affected by a number of factors,” said Dr Mohd Ismail.

These include risk of developing cirrhosis and liver cancer, limitation of existing therapies, and treatment initiated by generalists with limited skills in managing adverse events.

“Other realities include inefficient patient referral mechanism, inaccessibility to latest diagnostic and monitoring tools, high cost of treatment, and scarcity of basic and clinical research on liver diseases,” he added.

Dr Mohd Ismail also talked about the epidemiology of hepatitis in Malaysia and the government’s commitment to reduce the burden of the disease.

The setting up of a liver registry and expanding vaccination programmes were among the practical solutions to check the hepatitis threat, he said.

“Tremendous progress has been achieved in the treatment of chronic hepatitis C and the virus causing this disease can be eradicated,” he said, “but the hepatitis B virus can only be suppressed.”

Participants also shared their views and expertise on gastric cancer, which is the second most common cause of cancer-related deaths worldwide, according to Prof Kwong-Ming Fock, who heads the Department of Medicine at the National University of Singapore.

The incidence rates are highest in Asia and South America and lowest in North America, Europe and Australia.

The Chinese ranked the highest on the incidence scale of gastric cancer, followed by Indians and Malays, and males were more predisposed to the disease, he said.

“Studies suggest that genetic predisposition, Helicobacter pylori bacteria infection, and other exogenous factors such as diet can be associated to temporal sequence of pre-cancerous changes leading to development of gastric cancer,” he said.

University of Hong Kong associate professor Jia-Qing Huang said studies had suggested that 80% of gastric cancers were attributed to H. pylori infection.

Dr Robert Ding said nine patients who did not respond to the usual H. pylori eradication regime were successfully treated with a “rescue therapy” using dual high-dose Lansoprazole/Amoxicillin.

Eradicating H. pylori has been identified as one of the ways to prevent gastric cancer, but some studies are now showing that this strategy might lead to other implications.

H. pylori might have a protective impact against Barret’s oesophagus and adenocarcinoma, said University of Arizona Gastrointestinal Motility laboratories director Assoc Prof Ronnie Fass.

Assoc Prof Fass also advised doctors to be absolutely sure before diagnosing Barret’s oesophagus (changes in the oesophageal epithelium), saying that insurance companies in the United States would not provide medical coverage for such patients.

Barret’s oesophagus was not common in Asia, he added.

Cancer of the oesophagus carried a grave prognosis, said Chinese University of Hong Kong’s Professor of Surgery Sydney Chung.

“This is because the tumour would already be at an advanced stage by the time diagnosis is made, as symptoms do not appear until the tumour has grown to a considerable size,” said Prof Chung.

There had been a dramatic increase in the incidence of colorectal cancer over the decade, said University of Hong Kong Department of Medicine Assoc Professor Benjamin Wong.

He attributed this to the “Westernisation” of Asia, and also to the low level of public awareness about the disease.

“Public awareness on the need for early screening is very low. But even the doctors are confused because colorectal cancer screening is more complicated compared to screening of other types of cancers because of the various screening methods available,” he said.

“Faecal occult blood testing is the simplest non-invasive method for effective colorectal cancer screening.”

Assoc Prof Wong said identification and removal of adenoma (a benign epithelial tumour of glandular origin) was crucial to reduce the risk of development of colorectal cancer.

“After the removal procedure, it is important to perform surveillance colonoscopy periodically to check for new adenomas,” he said.

But gastroenterologists had yet to agree on suitable intervals to conduct periodic checks for various reasons, he pointed out, citing fear of malpractice as one of the reasons for this inconsistency.

A joint survey by Penang Medical College and Penang Hospital showed that respondents were not willing to undergo colorectal screening although a substantial number of them had relatives (13.3%) and friends (23.3%) who were afflicted with colorectal cancer.

Peter Lee, Professor of Surgery at the Penang Medical College, said the advent of high quality imaging had increased the accuracy of pre-operative staging and enabled more logical decisions to be made regarding the treatment options.

“Major surgery and possible permanent stoma formation could be avoided, as with improved staging techniques and transanal microsurgery, local resection for early rectal cancer can be considered,” he said.

On the possibility of using minimally invasive laparoscopic to cut colon and rectal tumours, Prof Lee said: “Although technically feasible, the place of laparoscopic surgery in colon and rectal cancer remains controversial.”