Monday, November 17, 2008


While browsing through the visitors in the "Live Traffic Feed-jit : Watch-in-Real-Time "column in my blog, I was surprised to learn that there are so many people anxious and worried about stomach cancer : some are survivors, some are patients, some looking for information and others with many enquiries and they all come from all over USA, UK and ASEAN countries.
I can understand how it feels when you or someone you love is afflicted with this stomach-cancer and how desperate and fearful it is to gather as much knowledge as one can about this illness. I told my surgeon Dr Ramesh about this and he is willing to answer the queries if the visitors will write in as comments into my blog and give their email address. I will do my best to forward all the queries to him to answer. This week (24 Nov - 26 N0v ) Dr Ramesh is attending a world conference on stomach-cancer in Hong Kong.

The patient from Mersing ( with the stent in his oesophagus ) is eating well and sounds cheerful. His next check-up with the surgeon is in January. The young doctor patient in KL has completed the 1st phase/round of chemo and radiation treatment. He is fine and promised to keep a record especially on his diet and nutrition which he will contribute to our stomach-cancer support group. Hopefully our future patients will have a guide and reference on what to eat and do while undergoing chemo and radiotherapy.

In August, after 6 or 7 months I have recovered; my family members and I went for blood tests through our family doctor at the Pathlab in Seremban. Thankfully everything is normal for me and my Helicobacter pylori is negative. BUT my husband and daughter were tested positive for H.pylori bacteria . My husband's reading is 60.9 +ve and my daughter's 113.0 +ve. We were shocked as both of them did not experience any stomach discomfort or pain. My son-in-law who is also living with us was tested negative. Quickly both my husband and daughter went to see my surgeon Dr Ramesh who prescribed 2 types of antibiotics and romesec omeprazole, a proton-pump inhibitor for them to take for a week or two. A month later, they went to the Pathlab and took a breathing urea blow test and were tested negative. Even my two young grandchildren ( 2+ years old and 6 years old) were tested and found to be negative. We all sighed in relief and thanked God.

Nowadays, we are careful in what we eat; we try to eat more vegetables, soups and steamed food. We all drink fruits and vegetables juices early in the morning three times a week, take our vitamins and supplements daily and do exercises according to our level of abilities. Sometimes we do go out to eat our dinner in the restaurants. We try not to be too paranoid and become health-fanatics but we eat and do things moderately, normally and use common-sense. We have many friends who recommend us (especially me ) to eat this and that food, seeds or plant-leaves in order to prevent recurrence of cancer and be healthy. Everyone of us has some cancer-cells in our bodies but we must make sure that our immune systems are strong enough to destroy them. So we must eat well, rest well and "listen" to our bodies by choosing our food wisely.

Sunday, October 19, 2008


This month, during the 3rd day of Hari Raya, Dr Ramesh called me to see a patient (aged 60) who came from Mersing in Johor. He had advanced carcinoma (cancer) of the oesophagus and he could not eat. So Dr Ramesh dilated his oesophagus so that he could eat a little. He was being discharged from Hospital Tuanku Jafaar Seremban (HTJS).

What touched the Doctor's heart is that he has two young children ( aged 8 years and 10 years ) now living on charity with his ex-employer's family as the patient's wife passed away 8 years ago of cancer. Dr R requested me and Ms Goh to see whether we could do anything to help the patient for the children's sake.

My husband and I managed to see the patient as he had missed the last bus to Malacca. Being the festival season, all the buses were full of passengers returning home or to work. He had booked a ticket for the earliest bus the next morning and got himself into a small budget hotel in town.

That evening over a cup of Horlicks, I saw how thin he is. He had great difficulty in swallowing even his own saliva. Every now and then, he got up to spit out his saliva. We were amazed to know that he traveled from Mersing to Kluang to Malacca and then to Seremban HTJ by bus or taxi. Each trip cost him about RM 100 one-way and his ex-employer is so kind to give him RM200 - RM300 for his expenses every time. Last year he stayed at HTJS for two months to complete his chemo and radiation therapy in Nilai. I gave him Ensure milk and asked him to drink often before he comes to see Dr Ramesh on 13 October.

The next day my husband found out that it took the patient a whole day to reach home late at night ( 8.30 pm). Meanwhile I contacted Ms Goh and she told me to get him have his identity card, his children's birth certificates and his bank book front page's details photostated and bring all these copies along. This is to facilitate the procedures of asking aid from the Welfare Department and if it is approved , the financial aid can be banked in straight into his bank account.

On Monday (13-10-08) Ms Goh and I met the patient at HTJS. He had travelled the whole night to reach HTJS for his morning appointment. Ms Goh got the necessary forms from the relevant departments for the patient and the Doctor to fill them up in order to get aid from the Welfare and MAKNA (National Cancer Council)

In Dr Ramesh's clinic at SOPD, we were told that the patient needs to buy either a RM2700 or RM3500 "stent" to insert into his oesophagus so that he can EAT TO LIVE. We were stunned and shocked! This was the first time that I heard a patient needs to cough up money as I thought the HTJS will supply the necessary things or medicine for free especially for poor patients. Unfortunately Dr R told us that the "stent" must be bought from a supplier in KL as the HTJS does not have this "stent". We need to find a sponsor/sponsors fast. It was so short a notice to find any. How long will this "stent" help him to live ? we asked. Doc said, "about 6 months". Ms Goh suggested to ask help from MAKNA but with the procedure and paperwork, the money will come in two months time. "Too late", the doctor said. Then Dr R wanted the patient to go home and come back again later. My mind was racing. Now it's Monday. How can we let this poor man travel a whole day back to Mersing and then to come back later again ? He is suffering and time is so precious for him. I asked doctor how soon can he do the insertion of the "stent" if we have the money ? "Tomorrow" the doctor answered. So I told Dr R to get the patient admitted to day as I offered to advance the money. Immediately Dr gave a call to the company in KL to have the supplier bring in the "stent" tomorrow. I only need to bring in the cheque at 3 pm the next day.

Dr Ramesh was very touched by my offering that he said he would gladly contribute some money for the purchase too. It was very big-hearted and generous of him but Ms Goh and I told him that he has done enough in trying to save patients. Ms Goh also said she will call up her friends to help out. She even said that she will give her money when her fixed deposit matures at the end of this year. Bless her heart ! I told her it's not necessary as I think my family can afford it. My children can help to contribute the sum. We were all thinking about the two children's future without their pa eventually.

The patient could guess that something was importantly discussed as he could not understand English. Ms Goh only explained to the patient that he needs to warded so that something will be inserted inside his gullet for him to eat food later.

Then we brought him to the hospital Welfare Department for an 'interview' and to fill up the forms. The lady officer said she will try her best and that the most he can have is a monthly allowance of RM300 for about 6 months or one year. "Good enough" we said and thinking how soon and fast will the money arrive ? We left with hopeful thoughts that at least this patient may get some money into his account. Still at this time, the patient doesn't know his critical condition. We saw him safely warded in HTJS in Ward 3 A.

The next day (Tuesday) at around 3 pm, my husband and I went to the X-Ray department at HTJS. We saw the patient lying on a bed wheeled outside the X-Ray room. He looked okay and calm. Then Dr Ramesh came out and saw us. He said that the supplier is on his way. While waiting, Dr R came out again and handed me a roll of money bills into my hand. I was surprised and quickly my husband and I politely declined his donation. I told Dr that Ms Goh has really found a sponsor ( a patroness from KL) who is happy to donate to a charitable and worthwhile cause.

God really moves in mysterious ways. There are so many good angels around and I thank God and ask HIM to bless Dr Ramesh, bless Ms Goh and the kind sponsor for helping unselfishly and unconditionally by coming to the "rescue" of this patient.

The supplier explained to us that the "stent" will take some time to expand fully in the oesophagus usually after being warmed up by the patient's own body temperature.
With this RM2700 stent, the patient can eat and drink hopefully well but he must take medicine daily to prevent the reflux and bile from coming up.
The other more expensive RM3500 stent has no need of medication.

On Wednesday, the patient was X-Rayed to make sure that the "stent" was properly inserted and functioning well.
On Thursday morning before his discharge, my husband and I saw him again. I told him to drink Ensure milk (given by Ms Goh) often and to keep us in touch. His next appointment with Dr Ramesh is due next month. We ask him to give us a call when he arrives.

Wednesday, August 20, 2008

Stomach Cancer Support Group

I realize that each individual has different symptoms of stomach-cancer.

About 2 months after my surgery, Dr Ramesh (a caring Upper GI consultant surgeon) referred two patients to me for moral support and encouragement to undergo surgery and treatment.

The first patient from Port Dickson lost a lot of weight (13 kg) and couldn't eat well. She was diagnosed as 1st stage in the beginning of November last year (2007) but she had been postponing her surgery dates three times. So when she came to see Dr Ramesh the fourth time and still hesitated to go for surgery, Dr Ramesh as a last resort asked her to see me as the best living example. By this time (in March when she saw me) her condition was in the third stage. I told her that time is precious and she got herself admitted into Hospital Tuanku Jaafar Seremban ( HTJS) The good doctor ran some tests and delayed her surgery because of hormone complications.Instead of getting herself treated for this, she discharged herself and went for alternative treatment. I was very disappointed and sad that I "lost" her. Until now, Dr R and I are still wondering and worried about her. I contacted her a number of times and she told me that she is taking medication from direct-selling friends, saw a faith-healer and practising a type of qi-gong cosmic energy healing ( reiki ? ). Recently she had a blood test and told me her liver reading is unusual. I advised her to see Dr R for a thorough examination. I can only pray and hope for her well-being.

The second patient (aged 50 plus) had no pain but had persistent vomitting. She went through the surgery (partial gastrectomy : 3/4 parts or half stomach taken out with surrounding lymph nodes) and recovered very well in HTJS. She made better progress than I did. I felt good seeing her recovered so well.

Compared to these two patients, my symptoms were different. I had gnawing pain in my abdomen that comes and goes for a few months. When I ate something, it's okay for a while; and then the dull pain starts again even at night. But I was lucky to be diagnosed as 1st stage, got a 1/4 stomach left , no lymph nodes infected and did not have to undergo any chemotherapy or radiation treatment.

After these two patients, Dr Ramesh refer other new patients to me. My daughter, Iris, and I help him to start a support group for stomach-cancer patients. We hope our group can contribute and help the patients to be hopeful and knowledgeable about pre-operation procedures and post-operation stay in the hospital to getting fully well again at home.
We recruited some cancer survivors as volunteers, health personnel from HTJS and National Cancer Council (MAKNA) to give us guidance, counseling and help to the patients.

In our small group of volunteers, we have :

~ Ms Goh, an experienced and dedicated member of MAKNA + an NGO Hospice in Seremban. She has survived and overcame 2 cancers of the womb and colon and underwent radiotherapy and chemotherapy. She is so knowledgeable about medical terms, paperwork and filling in forms for welfare aid and liaise with different departments and even follow the hospice nurse on her rounds of giving quality care to palliative and sometimes terminal patients . She has dedicated her life to servicing and helping cancer patients. We are very fortunate to have her in our stomach-cancer support group and I am learning from her.

~ Mr Kelvin, a one-and-a-half-year-old stomach-cancer survivor (aged 30+) who has completed his radiation and chemotherapy in Nilai hospital. He is an asset to our team as he helps to share his experiences and advises patients on diet and nutrition while undergoing chemo and radiation therapy. He is still working and travels daily to Shah Alam and KL from Seremban. If there are patients in KL he visits them.

~ Mr Foo, a veteran survivor ( aged 68 ) who has no stomach for 7 years. Many of the patients in HTJS are impressed and cheered by his visits as he is so full of life, jovial and has a round tummy. He is the best living testimony. He plays golf daily and his favourite motto is " Listen to your Body" and "Eat everything that is nutritious and healthy" "Must put on weight and no taboos or pantangs on what is right or wrong food". Patients must eat in order to get back as quickly as possible to normal daily life.

~ Mr Shan , a retiree whose wife passed away of stomach-cancer a few years ago. He is very helpful in communicating and counseling patients; and even translating our advice to the Indian patients so that they can get better. He finds great joy in helping the patients.

~ Iris, my daughter and my husband, Ivan, help me to advise the patients through phone calls on their diet and well-being when the patients speak in Cantonese or Mandarin. I can only speak in Hokkien and English well. Sometimes we visit the patients in HTJS for post-op care.

We started our first group meeting on 17-5-2008 with the good Dr Ramesh and MAKNA manager ( Mr Vemanna) and chemo ward staff nurse giving us some guidelines and advice on counselling. The HTJ social welfare officer was unavailable.

On an average, Dr Ramesh refer to us about 2 to 3 new patients in a month. We monitor these new patients and other old cancer-survivors' progress through phone calls, hospital and house visits. Most of these patients lost weight irregardless of whether they had stomach-cancer stage 1 or stage 4.

Example Patient A :
A female patient from Mantin ( aged 54 ) had partial gastrectomy last year (12-1-07) She lost weight from 65 kg to 44 kg. Her endoscopy was clear and okay, but Dr R is worried about her weight loss and refer her to me for advice on her diet and nutrition. She is too scared to eat certain foods because of taboo : like egg is " toxic" . I told her to eat more proteins and carbohydrates.

Example Patient B :
Another patient from Port Dickson (aged 38 ) had her stomach cancer cells spread to her ovaries and uterus which were taken out without realizing that stomach CA was the main cause. By the time she came to see Dr Ramesh, her stomach-cancer was in the 4th stage. She had Total Gastrectomy ( whole stomach taken out) and completed her radiation and chemotherapy 1+ 1/2 years ago. She was referred to me in July this year because of her acute weight loss from 90 kg to 50 kg. I told her to eat small meals often every 2 hours and drink Ensure / Enercal Plus in between meals and eat whatever she likes.
Sadly, she passed away early this month on 11 October.

Stomach-cancer has NO Respect for AGE or GENDER or PROFESSION. Anyone can get it at anytime. How or Why ? We don't know. Only that if anyone has gastric pain, abdomen pain, heartburns or indigestion that does NOT go away after being treated by GPs, please go for an endoscopy examination and blood test. If there are helicobactor pylori germs in the stomach, it can be treated with strong doses of 2 types of antibiotics and proton pump inhibitor drugs ( eg Romesec omeprazole or pantoprazole ) Please see your doctor as soon as possible for treatment.

(i) We have 3 patients with stomach-cancer in their 20s (twenties) :

~ A young mother aged 23 with a child had stomach CA stage 4 - very advanced stage as her legs were swollen. She came to see Dr R in June and Dr R couldn't do anything for her except refer her to Palliative Care Unit in HTJS. She passed away on 14 August.

~ A newly-wed woman aged 28 married a year ago and has no child yet. She had total gastrectomy ( stage 2) , completed her chemotherapy treatment and is now having poor appetite and weight loss. We are still giving her moral support and monitoring her condition.

~ A young doctor 28 years old from KL, still single and completing his internship in a Hospital in Negeri Sembilan. On 8-8-08 ( an auspicious chinese date) he had total gastrectomy (stage 2) as the CA cells were at the upper part of his stomach and spreading a little bit to his lower oesophagus. Because of this, he has to endure a drastic chemo and radiotherapy course in Nilai hospital. [Unlike me, my CA cells were at the lower part of my stomach. So the surgeon saved the upper 1/4 part of my stomach. I was very fortunate and I thank God daily for this ]
The first set consists of 5 weeks 5 days non-stop course of chemo and radiotherapy treatment ( 25 times) At present, he is now enduring the 4th week. After this , the second set will be 6 months : one month once 5 days of chemotherapy ( 30 times).

(ii) We have 2 patients in their 70s (seventies) and one patient at 83 years old

~ A lady aged 70 had partial gastrectomy done by Dr Ramesh. She is doing well in Penang and putting on weight after heeding advice on diet and nutrition and getting loving care from her daughter's family.

~ Another lady 73 years old from Port Dickson had partial gastrectomy surgery in July. She stayed the longest in HTJS for her post-op recovery. Since she is diabetic, her wounds took a long time to heal. Later she was admitted into Port Dickson hospital for her fainting spells. She was treated and given medication for her diabetes. On 15-9-08 she came for check-up and is doing fine. Her daughter said that she could eat well. Slowly she is recovering.

~ A lady aged 83 from Batu Pahat Johor , had 1/2 stomach left after her surgery was done in May at HTJS. She has high BP and thyroid complication. Her daughter lives in Seremban 2 and is worried about her poor appetite.

(iii) Most of the other patients are between the ages of 40+ and 60+.
They come from different districts like Pedas, Sepang and even as far away as from Ipoh Perak and Mersing in Johor.

We do have a few male patients even though the number of female patients are more.

~ A male patient businessman aged 40 had partial gastrectomy ( stage 2 ) last year. He has completed his radiation and chemotherapy only 10 times out of 30 times ( 6 months - one month 5 x ).
He is working with his brother's business in KL and travelling daily. Mr Kelvin and Ms Goh helped to counsel him to finish his treatment. We were happy and relieved when he came for his last chemo on 16-9-08.
[ In HTJS there is a Day Care Room in Ward 3B where the cancer patients can come and be administered their chemo injections for a few hours. ]

~ Another patient aged 47, an architect with a successful firm in KL, had partial gastrectomy (stage 1 ) on 12-9-08. Unfortunately his biopsy results showed that one of his lymph nodes is infected. So he will be undergoing 30 x chemotherapy treatment in Nilai for 6 months ( 1 month 5 x)

Sometimes, the family members have difficulty in convincing the patient to go for surgery. So Dr Ramesh will refer him/her to us. We will then do our best to encourage the patient to go to hospital and pay them visits to give moral support and help.
Often, I will bring Mr Foo, Ms Goh and other cancer-survivor friends especially those without stomachs as living testimony to the patients in HTJS before and after their surgery stay in hospital.

We felt good when the patients become cheerful and hopeful to know that they can become like us and some even offer to join our support group after they are well.

Monday, May 19, 2008

After 1 month recovery

To keep my immune system fit and healthy, I exercise , eat nutritious food like fish, cheese, chicken, lots of vege, tofu and drink fresh juices daily.

I go for morning walks around my neighbourhood and practise deep breathing exercises like breathing through one nostril deeply 3 times alternately, or thru one left nostril and breathe out thru the right nostril and vice versa many times. The morning air is cool and calm. I like to walk after a rainstorm. The air is energized with negative ions and it feels so cool and fresh.

Twice a week my husband and I go for qigong exercise at night. We practise the movements for Soaring Crane Qi Gong ( Hexiang Zhuan Qigong). They are graceful stretching exercises for the limbs and all body parts. My sister told me that some are like the Yoga poses that she practises. My husband and I found them interesting and not monotonous. We both learnt this qigong about 6 years ago before we shifted down to Seremban. I started practising this again after one and a half months after my surgery. This time I was more serious and practise it more regularly. At first I could not turn my body parts fully especially around my tummy, bending to my toes or knees. Where there is pain, I did not force my movement. By six months I can turn and make all the moves and twists without pain. There are 3 parts :- the 1st part got 5 routines making the crane bird movements, the 2nd part (Yik Jing Jing) has 8 routines and the last part (Park Tuan Jing) another 8 routines. The whole exercise lasts about half an hour, which I did daily in the mornings and evenings.

After 3rd month of my surgery I could go for my golf hobby with my husband.
In the beginning I played 6 holes. Now I regularly played nine holes. I enjoy walking on the greens and admired God's lovely nature in the surroundings. I'm so grateful to be alive and able to enjoy the game with my husband and friends.

Sometimes, during the mornings or evenings or at weekends , we paid visits to our dear friends and relatives who have helped us to get through my ordeal. We really appreciate their support and enjoy catching up on our visits and they were very happy to see me well and cheerful.

I felt a deeper appreciation for the gift of life. My family and I realized how fragile life is and we make changes to our diet like eating more plant-based food :- fresh fruits, vegetables, green tea, whole-grains and vitamin supplements. We tried to exercise at our own level of ability.
The most important thing is that our perception and beliefs about cancer and recovery change to a more positive and hopeful outlook.

We tried not to be too paranoid about being too healthy, too hygienic, going to extremes in being clean etc.. but be moderate, doing things normally but be more aware of what we eat and do daily to stay well.
Our circle of friends, relatives and family bond has improved and strengthened and we know we will be there for each other for any of life's unexpected knocks and trials.

Spiritually, I am thankful to God for sparing my life. Maybe there is a purpose, a mission for me to fulfil and accomplish. I humbly pray and ask Him to guide me to do what He wills.

Saturday, May 17, 2008

Symptoms of Stomach Cancer

Cover Story - FIT4LIFE, Sunday 20 January 2008

Guts and cancer


In the first of this two-part series, we look at the malignant diseases of the upper gastrointestinal tract.

THE early detection of stomach and oesophageal cancer may go a long way to improve chances of survival, experts say.

Lavanya* was only 27 when her doctor diagnosed her with stomach cancer.

“I had pulsing gastric pains for about a year, but I thought it was a normal stomach ache perhaps because I ate irregularly,” she said as she recounted how she became aware of her sickness.

An upper GI endoscopy can be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain.

“My friend had gastric (gastritis), so I self-medicated by sharing her medications. At first the pain went away, and I continued buying those medications from a pharmacy.”

It was only when the pain became unbearable and medications did not help that she felt it was time to consult a doctor.

“I was admitted into a ward to have an endoscopy (this is a broad term used to described examining the inside of the body using an lighted, flexible instrument called an endoscope) done.

“That was when the doctors told me that it was cancer,” she added.

Just like many others affected by cancers in the upper gastrointestinal tract (oesphageal cancer and stomach cancer), Lavanya came to the attention of doctors a tad too late.

Dr Ramesh Gurunathan ... 'Most of our patients come to us with stage III or stage IV cancers. At this stage, their five-year survival rate is only about 20% to 30%.'

Luckily for her, the cancer had not reached a severe stage (in general, the stage of a cancer tells the doctor how far it has spread, and it is important because treatment is often decided according to the stage of a cancer – the higher the number, the more severe the cancer) and now she’s recuperating after surgery and subsequent radiotherapy and chemotherapy.

“There are still a large number of people who come to us at stage III or stage IV stomach cancer... there are times where the cancer was too advanced and we could only offer palliative care to make the patient comfortable,” said consultant upper gastrointestinal (GI) surgeon Dr Ramesh Gurunathan.

Together with his team of upper GI surgeons Dr Ahmad Sudirman and Dr Grace Lim, they strive to educate the public and medical professionals about stomach cancer and the ways to detect the disease early as it could significantly improve survival rates.

Where stomach cancer is concerned, a lot of Malaysians are still unaware of the symptoms of stomach cancer because they relate those symptoms to benign diseases of the stomach, such as ulcers or gastric reflux, Dr Ramesh added.

Are these cancers common in Malaysia?

According to the WHO, stomach cancer and oesophageal cancer accounted for about 6.3% (1,500) and 1.7% (400) out of 23,965 deaths in Malaysia for the year 2002 respectively2.

Although that figure placed stomach cancer as the fifth greatest cause of death among cancers, the incidence of stomach cancer is actually experiencing a downward trend.

This is because we can now detect one of the most important contributing factors of stomach cancer, which is the bacteria Helicobater pylori (H. pylori), said Dr Sudirman. When we eradicate the infection, we stop the progression of gastric cancer development, he added.

Dr Ahmad Sudirman ... 'As there are many factors that could contribute to gastric pains, doctors need to check for other factors that may have caused the pain.'

If detected early, there are ways to treat or delay the progression of both cancers through surgery or therapy.

That is why although statistics are showing reduction in emergence of new cases; steps must be taken to ensure that people get screened early.

Who is at risk?

According to the US Report of the Stomach/Oesophageal Cancer Progress Review Group in December 2002, the risks factors that increase the chances of developing oesophageal (oesophagus= the hollow muscular tube connecting your mouth to your stomach) cancer are smoking, alcohol consumption, low intake of fruits/vegetables and Barrett’s oesophagus (abnormal changes to the cells in the oesophageal lining).

More prominent factors in gastric cancer are low socioeconomic status, increased age and being of Asian heritage.

However, for both cancers, age (more than 50 years old) and low intake of fruit and vegetables is the common risk factor4.

For gastric cancer, the bacteria H. pylori can act as a carcinogen (cancer causing agent) that leads to gastric cancer, Dr Ramesh said.

In Japan, the high incidence of gastric cancer has been attributed to their frequent intake of pickled or preserved foods.

According to Dr Ramesh, the Chinese have the highest incidence of stomach cancer in Malaysia.

How do I know I have these cancers?

“The most common symptom patients get when they have problems with their stomach is a discomfort on the upper abdomen, which they often call gastric,” said Dr Lim.

Unlike heart disease, where a bout of chest pain is certain to create alarm, stomach ache has always been viewed as a common occurrence.

Some may think that it was due to bad eating habits or something they had eaten previously.

“Chances are, they will go to a pharmacy and buy off-the-counter medications instead of having it checked,” Dr Lim lamented.

Dr Grace Lim ... 'The most common sympton patients get when they have problems with their stomach is a discomfort on the upper abdomen, which they often call gastric.'

Although it may well be due to bad food or irregular meals (among other things, like reflux, peptic ulcers, gastritis), abdominal discomfort should not be taken lightly.

“While there is no specific time you should wait before you seek a specialist’s opinion, you should always get a doctor’s opinion if the medications do not help your symptoms or if your condition worsens,” Dr Sudirman advised.

However, instead of taking medications (antacids) which masks the symptoms, it is better to seek professional advise as there are various tests to determine the origin of such discomfort, Dr Ramesh said.

We should educate the public so that they can actually remind their doctors to refer them for an endoscopy if their condition is prolonged or could not be relieved by medications, Dr Lim stressed.

When a person is over 40, have a family history of stomach cancer and is having other symptoms such as vomiting blood, passing black stools, experiencing unintentional weight loss and loss of appetite, we encourage doctors to refer him/her to a specialist for further investigation, Dr Sudirman added.

Some other syptoms to look out for are early satiety (you feel full easily, unlike your usual eating habits) and trouble swallowing food.

What are the tests for these cancers?

If you were to go for an (upper) endoscopy, it is the best way a doctor can assess the health of a person’s upper gastrointestinal tract (mouth, pharynx, oesophagus and stomach), said Dr Lim.

In a quick (less than 10 minutes) and simple procedure, an upper endoscopy involves you swallowing a thin and flexible tube with light on one end called an endoscope.

This scope will enable the doctor to observe the internal lining of the oesophagus and stomach.

It can be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain3.

To relieve the discomfort during the procedure, local anaesthesia and sometimes sedatives are given.

What you need to do is fast for at least six hours before the procedure. Fluids will also need to be limited so the doctor will have a better view of the stomach lining.

The advantage of an endoscope compared to x-rays is that the doctor can see abnormalities like inflammation or bleeding through the endoscope that don’t show up well on the x-rays3.

In the same sitting, the doctor can also insert instruments into the scope to remove samples of tissue (biopsy) for further tests.

Possible complications of this procedure include bleeding and puncture of the stomach lining. However, such complications are very rare.

After the procedure, you may need to rest at the facility for one or two hours until the sedatives lose their effect.

It is also advisable for people going for endoscopy to bring along a companion to accompany them home as the sedatives in their systems wear off, said Dr Lim.

When should I have an endoscopy?

If you are having gastric pains right now, there is no reason to panic and rush for an endoscopy to be done, Dr Sudirman said.

“As there are many factors that could contribute to gastric pains, doctors need to check for other factors that may have caused the pain.”

While Japan practises mass screening for gastric cancer due to its high incidence of the disease, a targeted screening may address Malaysia’s relatively lower incidence of gastric cancer, Dr Sudirman added.

Dr Ramesh and his team have started to do targeted screening for high-risk patients and have detected quite a number of early cases of stomach cancer.

They are also in the process of developing a checklist of symptoms that doctors can refer to when a patient comes to them for gastric pains.

“When the patient fits the symptoms listed, the doctors could refer the patients to upper GI surgeons to do an endoscope,” Dr Ramesh said.

*Names have been changed at the patient’s request.


1. What you need to know about stomach cancer by National Cancer Institute, US National Institutes of Health,

2. Causes of death and disease estimates by country by World Health Organisation, Department of Measurement and Health Information (Dec 2004),

3. Upper Endoscopy by National Digestive Diseases Information Clearing House, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, US,

4. Report of the Stomach/Esophageal Cancer Progress Review Group by US Department of Health and Human Services, National Institutes of Health, National Cancer Institute,

A visit to the doctor

LET’S face it. You probably don’t have more than 10 minutes to describe your symptoms to the attending general practitioner.

And for something as general as stomach pain, you might want to be more specific to help the doctor figure out what is the real issue behind the pain.

So, if you are going to your nearest clinic for another bout of gastric pain, these are the questions you may want to think about before your visit.

Doctors may also want to have a mental checklist when a patient comes to him for a bout of abdominal pain.

Patients: Describing your abdominal pain

  • Timing

    When did the pain start? How long did it last? How frequent is the pain throughout the day? Did you have a similar type of pain before? Does the pain coincide with other biological processes (e.g. menstrual periods, pregnancies etc.)?

  • Trigger of pain

    What triggers the pain? Is it before or after food or when you lie down? Did anything intensify the pain?

  • Location of pain

    Where exactly is the pain? Did the pain radiate to any other parts of the body?

  • Type of pain

    Describe the pain. Is it a dull, sharp, stabbing or cramping kind of pain? How severe is the pain? Do you notice any other changes (such as unable to move your feet) in other parts of your body?

  • Pain relief

    Did you notice anything that makes the pain worse? Does the pain worsen with food intake or when pressure is applied?

  • Stools

    Did you notice any changes in your bowel motions? Did you notice changes in your stools? (e.g. blood, black stools)

  • Weight loss

    Did you lose weight without trying? Did you lose your appetite?

    Doctors: If the patient’s response is ‘yes’ to most of these questions, doctors may want to refer the patient for further investigation.

  • Is the patient more than 50 years old?

  • Did the patient have any history of black stools (melena) in less than a year?

  • Did the patient have anaemia?

  • Did the patient have a sensation of early satiety/fullness?

  • Did the patient have persistent vomiting?

  • Did the patient have loss of weight?

  • Did the patient have difficulty swallowing solid food?

  • Did the patient have the gastric pain intermittently for less than a year or persistent for more than two weeks?

    Reference: Upper GI surgeons Dr Ramesh Gurunathan, Dr Ahmad Sudirman and Dr Grace Lim.

  • Diseases of the stomach

    Common conditions

    Helicobacter pylori gastritis, chronic active gastritis, peptic ulcer, gastric cancer, gastric lymphoma.


  • Dyspepsia, upper abdominal discomfort and/or pain, bloating, belching

  • Vomiting of blood, passage of altered blood

  • Anaemia, weight loss, inability to eat


    Endoscopy and biopsy of stomach tissue


  • Helicobacter pylori eradication in cases of H. pylori associated gastritis and peptic ulcer

  • Surgery for gastric cancer cases.


  • Chronic active gastritis has a risk of malignancy.

  • Peptic ulcers may bleed and perforate.

    Gastric cancer

  • Common cancer among Asians, especially males.

  • Surgery is the only form of cure.

  • Easy to detect by endoscopy and biopsy.

  • High chance of cure if surgery is done at early stage.

    Problems in Malaysia

    Patients present with advanced stomach cancer as symptoms of early stomach cancer are often mistaken as “gastritis” and treated with oral medication instead of referring for endoscopy.

  • In a nutshell

  • Ranked as the ninth most common cancer in Malaysian males and fourteenth among Malaysian females. 4.1% and 2.5% of all cancers reported in males and females respectively.

  • The Chinese are at highest risk, followed by Indians and Malays in both sexes.

  • Stomach cancer incidence starts to increase after 40 years of age.

  • About 1,400 Malaysians develop a cancer of this type each year.

  • Stomach cancer can occur in adults of any age, but rare below the age of 50 years. More common among men than among women. (1.4 times)

  • Risk factors – disease of lower socio-economic group-in relation to diet, salt preservation of food, pickled food.

  • Fresh vegetables and fruit are protective due to anticancer effect of vitamins A, C and E act as antioxidants.

  • Other risk factors – a bacteria known as Helicobacter pylori. This bacteria can be easily treated if detected, changes in the stomach lining like small polyps (growth), tobacco, obesity, family history.

  • To date, there’s no screening for patients with high risk in Malaysia as it is not cost effective. Screening is done only in high risk countries like Japan. Detection of early cancers is high due to screening.

  • Our patients come late due lack of awareness, most cancers are treated palliatively.

  • Our patients don’t recognise symptoms of gastric cancer – like central abdominal pain, passing blackish stool, vomiting, early satiety, unexplained weight loss and appetite.

  • N. Sembilan has started targeted screening for patients with high risk.

  • We are trying to detect early gastric cancers to improve survival of patients. A simple method is by upper endoscopy, done as a daycare procedure, under sedation. The procedure takes less than 10mins to perform. Biopsies can be taken to detect Helicobacter pylori, to confirm cancer and other problems, which might cause cancer.

  • Treatment for confirmed cancer depends on stage of cancer. Some cancers can be removed endoscopically if they are detected early. Others may need surgery and other forms of treatment like chemo or radiotherapy.

  • Treating stomach cancer which presents at the early stage will improve survival.
  • Cover Story FIT4LIFE, Sunday 27 January 2008

    Sad, benign guts


    In the conclusion of this two-part series, we look at the benign diseases of the upper gastrointestinal tract.

    ALTHOUGH stomach cancer can be a possible cause for stomach discomfort, there is no reason to panic when we experience pain in the stomach region.

    Dr Ramesh Gurunathan ... ‘When people describe their abdominal pain as ‘gastric’, they are usually talking about a condition called dyspepsia.’

    There are also some diseases which are not cancerous that could affect the health of your stomach as well, said upper gastrointestinal surgeon Dr Ramesh Gurunathan.

    For 26-year-old Mohd Sobree Johad, irregular eating habits and a penchant for hot and spicy food has taken a toll on his stomach.

    As a silat teacher, he would teach all day without taking solid food, except for the occasional cup of Milo and teh tarik to keep him going during busy days. When he finally sits down to have a meal, he spices up his meal with sambal and cili api.

    After three months preparing for a competition with those eating habits, he developed what he termed as “gastric”.

    “At first it was just a dull stomach discomfort when I eat after a long day without solid food, then it progressed to an excruciating pain that hits me intermittently throughout the day,” Mohd Sobree said.

    He then underwent an endoscopy and found out that there were infection and lesions in his stomach. Soon after, when the medications he took for about a year had ceased to assuage his pain, he was referred for an operation to remove part of his gastrointestinal tract.

    “At first I was unsure about the operation and delayed it ... now I’m just relieved that it is all over,” he added.

    Now, he is a changed man. Apart from eating more vegetables and staying away from spicy food, he is also determined to eat regularly and reduce his smoking.

    While traditional medicine may offer relief to symptoms of some benign diseases, it is also important to get medical consultation to diagnose your condition before embarking on any form of treatment, Dr Ramesh added.

    Many common diseases of the stomach such as the Helicobacter pylori (H. pylori) infection and gastroesophageal reflux may lead to more serious illnesses (such as stomach cancer and perforation of the gastrointestinal tract).

    “Besides endoscopy (which is the gold standard for diagnosing diseases of the stomach), benign diseases such as peptic ulcer and gastroesophageal reflux can also be diagnosed with other tests such as blood tests,” said Dr Ramesh.

    That is why your doctor may carry out other tests to rule out benign diseases before referring you for an “invasive” procedure such as an endoscopy.

    What do you mean by ‘gastric’?

    “When people describe their abdominal pain as ‘gastric’, they are usually talking about a condition called dyspepsia,” Dr Ramesh said.

    Dyspepsia, sometimes also known as indigestion, can be described as a bloated feeling and a feeling of discomfort in the stomach region.

    Other signs of dyspepsia may include a gnawing or burning stomach pain, nausea, vomiting or burping. However, signs and symptoms may differ between individuals2.

    “The pain may be caused by many contributing factors, including causes other than gastric (stomach) ones,” surgeon Dr Ahmad Sudirman said.

    “It may be due to diseases of the stomach such as stomach ulcers, gastritis, gastric reflux, cancer or other causes such as gall stones, inflammation to the pancreas, heart disease and lung infection.

    “But the most common causes of upper abdominal pain are still peptic ulcer and gastritis,” he added.

    If the symptoms of dyspepsia are persistent even with medication – and come with other symptoms such as sudden and unintentional loss of weight, having trouble swallowing solid food, persistent vomiting and passing black stools – you might need to seek medical assistance as soon as possible.

    Usually, blood and stool tests can be done to identify the cause of gastritis so that you can be treated accordingly. If further investigation is needed, you may be referred for an upper gastrointestinal endoscopy to examine your stomach lining

    Other than cancer, what could go wrong?


    There are a number of factors that lead to gastritis (inflammation of the stomach).

    It can be caused by drinking too much alcohol, prolonged use of drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen, certain chronic diseases such as pernicious anaemia (autoimmune disease) and chronic bile reflux.

    “Infection with H. pylori can also cause gastritis as well,” said Dr Sudirman, who emphasised that a proper diagnosis of stomach diseases should be done, as their symptoms are similar.

    Common symptoms of gastritis are abdominal upset or pain, belching, a feeling of fullness or burning in the upper abdomen. Other symptoms such as blood in your vomit or black stools may be a sign of bleeding in your stomach, which requires immediate medical attention4.

    Usually, blood tests and stool tests can be done to identify the cause of the gastritis so that you can be treated accordingly. If further investigation is needed, you may be referred for an upper gastrointestinal endoscopy to examine your stomach lining.

    The treatment of gastritis depends on the cause of the condition. If your gastritis is caused by an infection such as H. pylori, your doctor may prescribe antibiotics to clear the infection.

    As stomach acid irritates inflamed tissue in the stomach, treatment also usually involves taking drugs (antacids) to reduce stomach acids so that the healing process can be facilitated.

    ·Peptic ulcer

    A peptic ulcer is a sore in the lining of your stomach or duodenum (first part of your small intestines).

    The most common symptom of this condition is a burning pain in the gut that feels like a dull ache. It comes and goes for a few days or weeks and starts two to three hours after a meal. Sometimes it comes in the middle of the night when your stomach is empty and usually goes away after you eat3.

    Peptic ulcer is one of the most common causes of abdominal pain.

    According to the US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), H. pylori causes almost two-thirds of all ulcers. However, not everyone who has an infection will develop an ulcer.

    Other causes include the chronic usage of NSAIDs like aspirin and ibuprofen and rare disorders such as the Zollinger-Ellison syndrome.

    But isn’t peptic ulcer also about stress and spicy foods? Surprisingly, according to the NIDDK, neither of them causes ulcers. However, just like alcohol and smoking, they could make ulcers worse.

    Tests that could be done to diagnose peptic ulcers are a barium x-ray (you drink liquid containing barium and do an x-ray) or an endoscopy.

    Although it is benign in nature, peptic ulcers should not be taken lightly. As ulcers involve the erosion of the stomach lining, it may carry a risk of perforation (the ulcer has gone through the stomach or duodenal wall).

    Certain symptoms to look out for are black or bloody stools and bloody vomit. These could be signs of the ulcer damaging a blood vessel, stopped food from moving from the stomach into the small intestines or gone through the stomach wall3. If you have these symptoms, medical treatment must be sought quickly.

    Peptic ulcers can be treated by medication such as proton pump inhibitors, said upper gastrointestinal surgeon Dr Grace Lim. If there is a bacterial origin to the ulcer, antibiotics are given to kill the bacteria.

    ·Gastroesophageal reflux disease (GERD)

    Gastroesophageal reflux disease (GERD) is a more serious form of the common gastroesophageal reflux (GER)1.

    An endoscopy can show the examining doctor lesions in the gastrointestinal tract such as ulcers and growths.

    “Most of the patients say that they have burning chest pains which goes up to the mouth, and sometimes they have a bitter taste in their mouths,” Dr Ramesh said.

    “Some of them can’t sleep at night, because when they lie down after meals they feel a volume of acid going up (from their stomach). These are typical symptoms of reflux.”

    GER with atypical symptoms such as chronic cough and sore throat may be difficult to diagnose, he added.

    Food regurgitation and feeling bloated are also typical symptoms of GER, Dr Sudirman said.

    The reason some people develop GERD is still unclear1. However, one of the reasons associated with the disease is loss of tone in the stomach muscle that prevents the acid from the stomach from going to the oesophagus, Dr Ramesh said.

    The weakening of these muscles will allow the acid to go into the oesophagus, causing the burning sensation in the upper abdomen or chest, Dr Lim added.

    Other factors that may contribute to GERD include obesity, pregnancy and smoking.

    In a fact sheet on GERD by the NIDDK in May 2007,it is stated that there are a few common foods that can worsen reflux symptoms.

    They are citrus fruits, chocolate, drinks with caffeine or alcohol, fatty and fried foods, garlic and onions, mint flavourings, spicy foods and tomato-based foods such as spaghetti, salsa, chilli and pizza.

    “The way to assess a (gastroesophageal) reflux is to have an endoscopy done,” Dr Lim said.

    Dr Ahmad Sudirman ... ‘The most common causes of upper abdominal pain are still peptic ulcer and gastritis.’

    “Manometry studies to assess your muscle tone and pH studies to assess the pH levels in the stomach are also ways to confirm the diagnosis,” Dr Ramesh added.

    Depending on the severity of your GERD, treatment may involve one or more of lifestyle changes, medications and surgery.

    Examples of these lifestyle changes are smoking cessation, weight loss if needed, eating small but frequent meals, wearing loose-fitting clothes and avoiding lying down for three hours after a meal1.

    For Mohd Sobree, whose GERD had become serious, surgery was the best option.

    After his operation, Mohd Sobree reckoned that it was not as bad as he thought. Rather, he was relieved that he was finally feeling better.

    “Do not be afraid of going to the hospital ... seek treatment before it is too late,” Mohd Sobree advised.


    1. Heartburn, Gastroesophageal reflux, Gastroesophageal reflux disease (GERD) by National Digestive Diseases Information Clearing House, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health US,

    2. Dyspepsia: What it is and what to do about it by the American Academy of Family Physicians,

    3. What I need to know about peptic ulcer by National Digestive Diseases Information Clearing House, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health US,

    4. Gastritis by National Digestive Diseases Information Clearing House, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health US,

    Getting to know H. pylori

    SINCE its “discovery” in 1982 by Prof Barry Marshall and Dr Robin Warren, H. pylori has been extensively researched. Known to cause gastritis, peptic ulcer and possibly some cancers, more and more doctors are treating this infection seriously.

    What is Helicobacter pylori?

    It is bacteria found in the mucous layer of the stomach lining or first part of the small intestine, which causes more than 90% of ulcers1. Ulcers are sores in the lining of the stomach. Before 1982, when this bacterium was discovered, spicy food, acid, stress, and lifestyle were considered the major causes of ulcers. Since we now know that most ulcers are caused by an infection with H. pylori, they can be cured with appropriate antibiotics.

    Who gets H. pylori?

    About two-thirds of the world’s population is infected with H. pylori. In the United States, H. pylori is found more often in older adults, African Americans, Hispanics, and those in the lower socio economic groups.

    In Malaysia, it was found that the prevalence of H. pylori infection was higher in patients more than 50 years of age compared to those below 30 years4.

    It is still not known how H. pylori gets into the body or why some people with H. pylori become ill while others do not. The bacteria is most likely spread from person to person through the faecal-oral route (when infected faecal matter comes in contact with hands, food, or water) or the oral-oral route (when infected saliva or vomit comes in contact with hands, food, or water).

    How does H. pylori get into the stomach?

    Although much research has been devoted to determine how Helicobacter infections are acquired, the simple answer is that, with the exception of a few patients who have been infected during gastric endoscopy, we don’t know how this organism is introduced into the stomach.

    An update in January 1997 suggested that food contaminated with the bacteria may be the route of infection. Adequate nutritional status, especially frequent consumption of fruits and vegetables and of vitamin C, appears to protect against infection with H. pylori.

    In contrast, food prepared under less than ideal conditions or exposed to contaminated water or soil may increase the risk of infection.

    What are the symptoms?

    The most common symptom of ulcers are gnawing or burning pain in the stomach area, between the breastbone and the navel. Commonly, the pain occurs when the stomach is empty, between meals and in the early morning hours, but it can also occur at other times of the day.

    Less common ulcer symptoms include nausea, vomiting, and loss of appetite. Bleeding can also occur and prolonged bleeding may cause anaemia leading to weakness and fatigue.

    If the bleeding is heavy, vomiting of blood or passage of bloody stools may occur. Dark stools or dark vomit often indicate old bleeding.

    How is H. pylori infection diagnosed?

    Doctors have several methods to test for H. pylori infection. By measuring antibodies against H. pylori, blood tests can determine if a person had been infected.

    A breath test (urease breath test) can determine if H. pylori is still present in the patient’s stomach. In this test, the patient is given a harmless substance to drink; some of the residue from the substance is broken down and exhaled in the breath. By collecting this breath, the healthcare provider can determine if H. pylori is present.

    A doctor can also perform endoscopy, in which a small flexible instrument with a camera inside is inserted through the mouth into the throat, stomach, and intestine to look for ulcers.

    During endoscopy, stomach lining tissue samples can be obtained. Several tests can be performed on these tissue samples to determine if a patient is infected with H. pylori.

    What is the treatment for H. pylori?

    The treatment for H. pylori infection consists of one to two weeks of one or two effective antibiotics. Successful rates range from 70% to 90% depending on the regimen used. Antibiotic resistance and patient non-compliance are the two major reasons for treatment failure1.

    Sources: 1. Helicobacter pylori Fact Sheet, US Iowa Department of Public Health, July 1998, 2. Helicobacter pylori, US University of Wisconsin Food Research Institute, 3. Helicobacter pylori: epidemiology and routes of transmission, by Brown LM, Epidemiol Rev.2000;22(2):283-97. 4. Helicobater pylori infection in Malaysia, M Z Mazlam, Malaysian Medical Association,

    FIT4LIFE, Sunday 27 January 2008

    Chemotherapy 101

    Too many myths surround chemotherapy. It’s time for the facts, and only the facts.

    I AM losing my hair and it is not because I am receiving chemotherapy for cancer. It is because I pull out my hair each time a patient tells me, “I don’t want to undertake chemotherapy because chemotherapy kills the good cells as well as the bad cells.”

    This is told to me in all its Hokkien and Cantonese variants. Can someone try to translate this statement to Bahasa Melayu? I hear this unfounded statement several times a day!

    We ascribe human attributes to rocks, trees and mountains and infuse them with a spirit. Is there a word for this? I think it is paganism. It seems now that the cells in our body can also take on human characteristics.

    There is no such thing as “good cells”. Even if we were to use “good cells” to mean normal tissues (as opposed to “bad” or cancerous cells), chemotherapy does not kill good cells. Not in the sense of annihilate, decimate or exterminate. Not with any finality.

    Chemotherapy is used a lot in nations which have emerged from the pre-scientific era: North and South America, Europe, Australasia, most of Asia that is not at war, north of the Sahara and South Africa.

    An example of a chemoport through which chemotherapy drugs can be delivered. This one is inserted into the abdomen.

    Almost all patients with lung, breast and colorectal cancer will need chemotherapy in both the early and advanced settings. Patients with nasopharyngeal cancer (NPC) and cervical cancer will need chemotherapy given at the same time with radiotherapy. The list of cancers treated with chemotherapy goes on and on.

    It is true that chemotherapy suppresses bone marrow function. The three kinds of blood cells produced by the marrow that concern us here are red blood cells (RBCs), white blood cells (WBCs) and platelets.

    This important side effect is not such a problem these days. A lowering of RBCs (anaemia) can be easily treated with a combination of a good diet (lots of red meat, please), iron pills, blood transfusion and a drug called epoetin-alpha.

    We oncologists always ensure the patient’s RBCs are adequate during chemotherapy to prevent tiredness, fatigue and a poor quality of life.

    A lowering of WBCs makes a patient more prone to fever and infection. Again, this is not a problem. We have a drug called filgrastim (and its long-acting sister, pegylated filgrastim) which is given to prevent WBCs from becoming dangerously low.

    Nausea, retching and vomiting are dreaded side effects of chemotherapy. This is much better managed today.

    At your first chemotherapy session, your oncologist will prescribe an anti-emetic i.e. an anti-vomiting drug. If you still vomit badly despite the anti-emetic given, make sure your oncologist formulates a more effective cocktail at your second and subsequent chemotherapy courses.

    I give you a checklist of the drugs you may need either singly or in combination to prevent vomiting: metoclopramide, dexamethasone, ondansetron/granisetron/tropisetron (one of these three will do) and aprepitant.

    The problems of diarrhoea and its converse, constipation, plague some patients undergoing chemotherapy. If there is diarrhoea, avoid a high fibre diet. There are also many effective anti-diarrhoeals e.g. loperamide, diphenoxylate, dihydrocodeine.

    If you are all bunged up, a laxative will help. There is no point in loading up on fibre, bran, fruit and vegetable to combat constipation. It is too much hard work. Also, your intestines will not tolerate such a load (99% of which is destined for the loo the next day anyway) during chemotherapy.

    “Burnt”, “scalded”, inflamed veins are a thing of the past with the introduction of the chemoport. This is a device implanted beneath the skin below the collar bone. It allows chemotherapy, drugs and intravenous fluids to be given with ease. Blood can also be taken for examination from the chemoport.

    Certain chemotherapy drugs (adriamycin, trastuzumab, lapatinib) may cause damage to the heart. It is imperative to measure the cardiac function before such drugs are given and thereafter every three months. With this precaution, hardly any patient will suffer from chemotherapy-induced heart disease.

    Sadly, there is no effective way of preventing hair loss induced by chemotherapy. But, hey, this is the time to be creative. Hair scarfs, bandanna and tudung come in all shapes, fabrics and colours. Hair pieces can give you a new vibrant look.

    Also, to some, a shaven head is a fashion statement (think of sexy Yul Brynner or even sexier Persis Khambatta).

    Of course, not all chemotherapy drugs cause alopecia (medical term for baldness). Gemcitabine, pemetrexed, vinorelbine, oxaliplatin and liposomal doxorubicin are some drugs that do not cause significant hair loss. However, these drugs may not be suitable in your case. Remember, cancer is 1,000 disease entities.

    The other phrase that makes me pull out my hair is “This herb and this health supplement will boost my immune system during chemotherapy.” I shall discuss this in another article.

    And so, like the ancient mariner, I shall stoppeth one of three or maybe even one of two to tell my tale again and again. The tale about chemotherapy curing cancer and prolonging good quality life. About how to overcome chemotherapy-induced side effects. About how almost all chemotherapy-induced side effects are temporary, reversible and manageable.

    I have to persevere in my quest in educating the credulous public and the unfortunate cancer patients. I have to keep on dispelling the fears and misconceptions about cancer and cancer treatment. I have to re-educate people about “good versus bad cells” and “boost the immune system”.

    Or else, I will soon have a bald pate!

  • Dr Albert Lim is a consultant oncologist. For further information, e-mail The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
  • Sunday, March 16, 2008

    Convalescencing At Home

    First Week at Home ( 12-2-08 ) ( Tues )

    Today my family brought me, a 56+ year old woman, home. It's good to be home. My family has taken the trouble to make the downstair's room comfortable for me. My son-in-law has taken my 2 grandchildren to his mum in Pahang. Eventhough I missed them greatly, I understood the reason. My family and close relatives have shown tremendous love and support in caring for me. My sister-in-law would cook the food for me and the family. I just have to rest and get well.

    A million thanks to the doctors, nurses and support staff in the hospital for their dedicated attention and care towards me and my daughter. They were very friendly and hardworking. The doctors often asked me about my well-being, encouraged me to keep practising breathing up the balls and motivated me to sit, move and walk. Their bedside manners were so wonderful that they managed to 'get rid of' me in a week's time. I can't thank them enough for getting me back to my home so quickly.

    Friends and relatives popped by to see and offer their help. They even brought along some friends who were survivors of stomach cancer. Their ordeal was worst than mine and yet they are now full of life and vitality. One has survived 9 years ago, another 7 years ago (both of them without stomachs : total gastrectomy ) - I admired their courage and was inspired by their spirit and zest for life. Friends are like valuable treasures - they rally around to give help unconditionally and boost up my morale with their laughter, jokes and sensible advice.

    For the first few days, I rested a lot. I needed help in getting up and lying down on the bed. I placed a fat pillow to support my back whenever I sat on the sofa. I needed someone to sponge me and wash my hair while I sat on the toilet seat.

    Daily my family members gave me physiotherapy, that is "beating" with cupped hands on my shoulders, chest, back especially my middle and lower back which ached a lot.

    I took some fish porridge for lunch and dinner (about 1/5 rice bowl amount) In between I drank Enercal Plus (about 50 to 75 ml) I weighed 47 kg (original weight before operation was 50 kg)

    My bowel movement for the first few days was sticky guey greenish grey, just like a newborn baby. Starting from Thursday (14/2/08) I took my fresh raw juice concoction. Usually they were an apple, 2 stalks of celery and a carrot. So throughout the week my bowel movement was twice daily.

    By the end of the week I could climb up the stairs to my bedroom, just in time to welcome back my grandchildren home. Soon it would be the usual routine of looking after them. The surgeons must have done a good job inside my abdomen for me to recover fast.

    Second Week ( 19-2-08) (Tues)

    Today I saw that my stool was formed : first part black and then full normal brown yellowish stool. I was happy as it showed that my insides are getting back to normal. My without-stomach cancer friend told me that his stools could never be formed, forever loose and in pieces. Compared to him I felt blessed and grateful to God.
    From today onwards my bowel discharge is normal and back to my daily morning habit.

    I could sit up from bed easily but I still cannot cough, sneeze or yawn fully - just a little cough will get my insides painful and tensed. A 1/4 laugh also felt so painful. I could eat some "meehoon kuey" soup, scrambled egg and papaya at different times of the day. I tried to eat some solid food every two hours - only a small amount about 50 - 75 ml. In between I drank fluids, clear chicken soup and even some boiled chinese herbs to strengthen my immune system ( 3 pieces puk kee + tong sum, a small handful of kei chi(wolfberry) and red dates boiled overnight in a slow-cooker)

    On Friday I got a shock when I found out that I weighed 46 kg - 1 kg less in a week. So I tried to eat more as I was worried. I ate too quickly and I found my abdomen feeling very uncomfortable. Too late I realised that my stomach was too small to take in a lot. I couldn't sit down, so I kept walking up and down the house for more than half an hour. It was a terrible painful feeling.

    I remembered the other day when I forgot to eat something after 2/3 hours, my tummy got upset like got wind inside. I experienced the same uncomfortable feeling. I tried to walk about until I burped or belched out air many times. I even drank one tablespoon of Gaviscon liquid.

    After these two incidences, I am more careful to eat slowly, in small amount and at regular times after every 2 hours.

    Third Week ( 26-2-08 ) (Tues)

    I felt much better. I discovered that I can fold both legs and sit cross-legged comfortably. On the bed I could roll from side to side - my right side felt better than the left. There were two lumps one in my left chest ribs and the other inside my left abdomen which felt painful if I lie on my left side.

    I took a full bath as I could now bend comfortably and use soap to sponge my skin.

    I noticed that there was a white patch with painful muscle underneath on my right upper inner thigh. This lump felt painful and hard. I applied Counterpain cream and massaged it everyday. Slowly, that spot of "lazy sleeping muscle" woke up and got well before I could tell it to my doctor during my next appointment with him.

    Every two hours, I would eat some solid food with liquid in between hourly.The amount is very little like 1/2 of a slice of bread and 50 ml - 100 ml liquid. Roughly, my daily routine would be as follows :

    • 7:30am 1/3 bowl of porridge oats
    • 9:00am Fresh juice of raw vegetables or fruits
    • 10:30am Protein snack/Steam Egg/Boiled Egg with toast/Scrambled Egg with Bread
    • 12:30pm Chicken/Fish Porridge or Chicken Rice
    • 1:30pm Protein Drink/Yogurt(Yakult)/Herbal Drink
    • 2:30pm Snack/Cheese and Bread
    • 3:30pm Soya Drink/Yogurt Drink
    • 5:00pm Steam Fish with Tofu,Brocolli/Carrot/Green Vegetables
    • 6:00pm Chicken Soup/Red bean porridge/Sweet Potato Soup
    • 8:00pm Biscuit/Snack
    • 9:30pm Protein Drink(Enercal Plus Milk)

    Every morning I took a morning walk around my neighbourhood. When I was in the mood I did some light stretching exercises to tone up my muscles as I found that my skins around my arms and thighs were flabby and loose - no flesh.

    For the first two weeks I wore very loose clothing and sarong. The third week I discovered that I could fit into my old clothes as I got back my girl-fiqure shape before marriage. This was the plus advantage of my post-op. Still I am careful not to wear any pants with the waistline near the wound scars. I tried to wear those with below the waistline - the hipster types.

    Fourth Week ( 4-3-08) (Tues)

    This week was uneventful - just the daily routine. My relatives came and my family brought them out for dinner at the restaurants. I tried to eat some of the non-fried, non-spicy food such as tofu, stir-fried vege and steamed fish. My relatives commented that I ate like a bird's ration. At home I ate a little of the different variety of vegetables such as broccoli, spinach, sawi, lobak, yao mak, etc. and a few slices of fruits like pear slices, apple slices, dragon fruit, banana, and papaya. My weight was and is 45 kg (100 lbs) till now and I try to maintain it. My daughter envy my weight and my slim body figure.

    Monday (10-3-08)

    Today was my appointment day with Dr Ramesh. He told us that my stomach biopsy is good as the lymph nodes are clear and everything is okay. BUT he is worried that the type of cancer cells I had (poorly differentiated adenocarcinoma ) were aggressive and invasive types. He suggested chemotherapy treatment - 1 month 1 chemo for 6 times. This is to play it safe in order to eradicate the C cells from my blood stream. I was not happy and unsure as I knew that the chemo will kill off some of my healthy cells. Dr Ramesh reassured me and asked me to rest well at home and build up my strength. He will see me in 6 weeks' time. Meanwhile he will consult with another oncologist about my case. He also advised me to have vitamin B12 jabs every 3 months so that my iron and folate acid can be absorbed well into my body.

    Dr Ramesh wanted to start a support group for stomach-cancer patients for there is none at present in the hospital. I am interested and agreed to help in any way I can. This blog is part of the reason I write my experiences before my grey cells deteriorate. Hopefully others will find it useful and learn something from it.

    The important thing is to listen to the doctors especially after surgery, have a positive outlook, be knowledgeable, trust in God and modern medicine and do everything within one's means to lead and live a healthy life. e.g. Eat healthy food, drink juices, do exercises, meditate, participate in social activities, contact friends, be HAPPY and LISTEN to your body.

    Friday, March 14, 2008

    Useful Sites for More Information & Help

    This organisation provides volunteer support to cancer patients especially in terminal stages. But, they also cater for monetary needs and moral support too.

    • MAKNA (Majlis Kanser Nasional)
      BG 03A & 05 Ground Floor,
      Megan Ambassy,
      225 Jalan Ampang,
      50450 Kuala Lumpur, Malaysia
      tel:+603-2162 9178 fax:+603-2162 9203
    Look up at this site too for my story published by MAKNA on Neoplasia Quarterly edition Q1 & Q2 2008 at :

    These are the sites that I went through to gain more knowledge for myself as I believe that the more I read and know about my condition, the more prepared I can take care of myself and have less fear.

    Thursday, March 13, 2008

    Dietary Information

    Partial or total gastrectomy patients' diet is very important. There was not much info or help obtained from the local hospital dietitian as their menus were catered for general.

    Patients after this surgery will only have part or none of their stomachs in their bodies, thus nutrient absorption is important to retain and regain their weight and strength.

    Below are some very useful information that an overseas doctor and dietitian friend have provided and I would like to share this as it does help me and given me ideas on how I should plan and take my meals as well as what type of food I should take.

    Good Nutrition after a Gastrectomy

    Some of the problems that may occur after a gastrectomy (removal of part or all of the stomach), are early fullness, weight loss, anaemia and dumping syndrome.

    Dietary recommendations to help overcome these are:-


    Early Fullness

    * Eat small frequent meals. Spread your food throughout the day. Have 6-8 small meals rather than 3 large ones. This will get less with time.

    • Avoid fluids with meals. Drink ½ - 1 hour before or after your meal when your stomach is not so full.

    • Chew food well and don’t rush over meals.


    Vitamin B12
    If you have had all of your stomach removed, Vitamin B12 can no longer be absorbed. You will require regular Vitamin B12 injections. In my case, doctors have advised me to take this every 3 months eventhough I have 1/4 of a stomach. This helps the nutrient absorption.The medicine can be bought at any pharmacy( in liquid ampuoles type ) and brought to any normal clinic for the doctor to administer the injection.

    Weight Loss

    • Focus on high protein foods. Include ‘protein foods’ with all your meals eg. milk, eggs, fish, poultry, nuts, beans, legumes (beans and lentils), yoghurt and cheese.
    • Use high protein milk ( Enarcal Plus / Ensure ) whenever possible (see recipe) eg. in desserts, sauces, milk drinks.
    • Have nourishing meals and snacks eg. cheese and biscuits, milk drinks, yoghurt, scones, raisin toast, dried fruit, nuts, peanut butter on bread, sandwiches, milk desserts, scrambled eggs, steamed eggs with minced meat and tofu.
    • Replace fluids such as tea, coffee, clear soups, water, with milk, egg flip, milkshakes, thick soups like chicken soup, mushroom soup, fish porridge or congee.
    • Weigh yourself weekly. If you are losing weight, contact your dietitian for further assistance.
    Sample Meal Plan


    Fresh or canned fruit
    Egg / Cheese
    Bread / oats
    Margarine / Butter
    Vegemite / Bovril / Marmite
    * 1 glass high protein milk (see recipe below)

    Sandwich / Butter / Margarine
    - Meat, Cheese, Chicken
    - Salad, eg tomato, lettuce, broccoli, spinach

    Fresh or tinned fruit
    * Tea/Coffee with milk

    Meat / Fish / Chicken
    Potato / Rice / Pasta
    Vegetables or Salad
    * High Protein milk
    Morning Tea
    Afternoon Tea

    Crackers and Cheese
    Scones and margarine
    Yoghurt / Custard / Milk Pudding
    Fresh or canned fruit

    * Drink 30 - 45 minutes later, half an hour before meals or an hour after meals.

    Snacks or Supper

    • Biscuits and cheese

    • 1/2 a sandwich with protein

    • Toast, raisin toast

    • Scone, crumpet, muffin &

    • Milkshake, flavoured milk/

    • Supplement drink eg
      Sustagen, Ensure, Enercal Plus

    • Yogurt

    • Boiled egg

    • Cake, biscuits

    • Muesli bar

    • Chocolate

    • Fruit salad and yogurt

    • Corn chips. Potato chips

    • Instant noodle with protein meat, fish

    • Fresh or Canned fruits

    • Left overs
    Recipe for High Protein Milk

    60g (¾ cup) skim milk powder
    500mls (2 cups) milk
    Beat together

    Add flavouring or pureed fruit as desired.

    Use as a base for milkshakes, eggflips and in soups, sauces and desserts.

    Dumping Syndrome

    Dumping syndrome occurs to a small number of people following a gastrectomy. It is caused by the rapid dumping of food in the intestine. Two types of dumping can occur. Early dumping (15-30 minutes after meals) this can cause nausea, vomiting, stomach bloating, cramping pains and diarrhoea. Late dumping (occurs 2-3hrs after meals) is associated with palpitation, sweating and drowsiness.

    Dumping syndrome can be avoided by:-

    • Avoiding drinking with meals. Fluids should be taken 30 minutes before or after meals.

    • Have small frequent meals. Avoid very hot or very cold fluids and foods.

    • Eat slowly and chew food well .

    • Avoid foods containing large amounts of sugar. Sugar is emptied rapidly from the stomach resulting in the symptoms above. Some high sugar containing foods include:-
      - soft drinks, cordial, fruit juice, flavoured mineral water, cakes, biscuits, chocolate, honey.

    • Avoid alcohol.


    • Sweetened cereals, donuts and sweet rolls

    • Frozen or dried fruit, fruit cooked or canned with sugar,
      sweetened fruit juice, prune juice.

    • Malted or chocolate milk, sweetened custard, pudding or

    • Cakes, cookies, pies, ice cream, jams, honey, lollies.

    • Carbonated drinks.


    * Chicken rice

    * Dumplings ( har gow, dim sum, siew mai)

    * Chee cheong fun

    * Fish ball / paste noodles

    * Pork, chicken, beef meatballs with beancurd + a dollop of sesame oil

    * Soya drink , tau foo fa ( any milky pudding)

    * Steamed fish with bean curd

    * Steamed minced meat and egg (with tofu)

    * Porridge / Congee with fish, minced meat , egg, ikan bilis

    * Bubur cha cha

    * Red / green bean soup

    * Stir-fry vegetables -- leafy vegetables should be chopped up and chewed well

    * Midmeal snacks -- small serving of peanuts, almonds, cashews, pumpkin or other seeds ( must chew well and finely :- very important )


    Daily I drink 2 types of raw vegetables and 2 kinds of fruits. I used an electric juicer to extract the liquid which I drink immediately in order to prevent oxidation. In this way I hope to keep myself healthy and avoid falling sick.

    Eg : 1 Carrot + 2 stalks of Celery + a large red apple + a large orange
    1 Carrot + + Cucumber + a green apple + a guava

    Raw Vegetables ..................................Fruits
    Carrot....................................................... Green / Red Apples
    Leek ..........................................................Guava
    Beet root ..................................................Pineapple
    Broccoli .....................................................Star fruit (carambola)
    Spinach .....................................................Orange
    Cabbage ....................................................Pear
    Cucumber .................................................Mango

    You can mix and make any combination of fruits and raw vegetables according to individual taste and how palatable you can swallow.
    In the beginning, I could drink only 100 ml of the juices. Slowly I increase it to 150 ml, 200 ml and now after a month I can drink a full cup (250 ml)

    Liquid Diet

    For the first few days after surgery, I drank enercal/ensure milk, water, plain milo, soya milk, watery porridge / broth, strained chicken or vege soup, cereal / oat porridge plus enercal/ensure milk, yogurt drink, etc. Fruit and vegetable juices are an important daily drink. Slowly I increased the amount of liquid from a quarter bowl to half a rice bowl.

    Later I change my liquid diet to a soft and low residue ( no high fibre) diet. For example, I soaked half a slice of bread or a cracker biscuit into my milk. I ate more steamed white flesh fish like pomfret, tofu slices, blanched broccoli, sawi or kale and carrot slices.

    Post-Op Stay in the Hospital - Diary

    This diary was recorded by my daughter, Iris, as I was too weak
    and slowly recovering from the operation in Ward 8B.

    5-2-08 (Tues)
    Dr Jacinta gave anesthetic Epid Cocktail - dosage increase from 6 mg/hr to 8 mg/hr ( 1.30 am)
    She explained that if given more, my mom's BP will drop and heart beat will be slow. Mom is still in pain and could not get up to sit. She wore tight stockings to prevent blood clotting. A nose tube to drain out the 1/4 stomach fluids, Intravenous drip tube for sodium chloride / glucose to feed mom thru her hand vein , Urine tube to drain her bladder.

    6-2-08 (Wed)
    Morning 4.30 am fever 38.2*C. Used a wet towel to sponge mom. Her abdomen, throat and nose painful. Can hardly speak up as her throat is painful after surgery insertion. Sleep mostly.

    7.00 pm epidural machine seem faulty as a sharp beep keeps on alerting. Called Dr a few times but due to festive CNY holiday , only one Dr is on call and she is busy in the ICU unit.

    Dr Balen, the anesthetic Doc, came at 11.30 pm to change the epidural machine and medicine to morphin. They took out the epidural needle as the tube is clogged. Morphin given through vein (near wrist) and manual control (ASP) by patient. Each time mom presses the button, 1 mg of morphin is inserted + m/c will be locked for 5 mins before the next insertion can be made.

    7-2-08 (CNY) (Thurs)
    With this morphin, mom can be propped upright in the sitting position in the morning. Her legs did not feel numb + can fold up slightly + can talk too. She has a plastic gadget named TRIFLO II consists of 3 plastic balls in 3 columns. It is a breathing exerciser tool. Mom can breathe one ball up high (max level) but Dr wants her to breathe 2 balls up. She must practise it hourly or as much as possible. Dr wants her to sit on high chair tomorrow.

    Mom gargled and spit out the water to keep her mouth + throat wet. Mom is on NO liquid + solid diet. Slight fever at 9.00 am ( 37.4*C). She is on oxygen tube. Her left hand is swollen. Dr Maha asked Dr Azahana to change the intravenous injection outlet to the other hand. At 12 pm the nurses change the tubes and morphin medicine to the right hand.

    8-2-08 (CNY) (Fri)
    Right hand also slightly swollen. Was asked to shift from Bed 23 to Bed 17. In the afternoon my brother+ Dad got mom on a high chair beside the bed at 4.00 pm. Manage to sit for about 2 hours.

    When Mom stands up she can move her legs up + down a few times to exercise. Today fart also. Urine is clearer. Mucus from nose tube no more but need to keep it on another day to monitor. Oxygen tube was taken off.
    Used cupped hands to beat mom's chest and back to loosen phlegm /mucous in her lungs.(pysiotherapy) Mom feels and sounds better after doing this. ( Did this "beating" for mom every morning + night during her stay in hospital).

    9-2-08 (Sat)
    Morning help mom to brush her teeth with a small empty pail + a cup of water with straw.
    9.45 am mom able to walk to + fro ten small steps before sitting on the high chair. Dr Azhana informed us that Dr Ramesh has given the green light to take out the nose tube and urine tube.
    Have to check with the anesthetic Dr first to take out the morphin machine as it is difficult to go to the toilet with it.

    10.00 am - Nose tube taken out
    10.30 am - First sip of clear water
    10.40 am - 20 ml water
    11.30 am - 20 ml water
    12.30 pm - 25 ml water

    8.30 pm - 50 ml water

    10-2-08 (Sun)
    Morning able to walk to toilet. Morning walk one round the ward to the door and back.

    9.00 am - Can breathe one + 1/4 balls up on her plastic gadget

    10.30 am - Dr Ramesh came + said that mom can take some milo with milk powder. Requested
    to go into first class ward as the present ward is too congested + noisy because of accident patients.

    Afternoon move into ward 2C ( 4 patients in a room) with air-cond + nearer bathrooms. Morphin PCA taken out + substitute with painkiller pills.
    8.00 pm - mom drank 1/3 cup milo plain( no sugar + milk)

    11-2-08 (Mon)
    Dr Ramesh + Dr Grace came. Inform nurse to take out drip + stockings. Can start on porridge + probably be discharged on Wed or Thurs.

    Mom took some milo with evaporated milk ( Hosp has no milk powder) Mom 's tummy felt uneasy. Probably will skip the evaporated milk next time.

    Blood test for potassium ok.
    9.00 am : BP 117/72 -ok. No fever

    10.30 am: Mom got diarrhoea + felt fainting + weak
    Blood sugar checked ok (7.8)

    Dr Marie came and gave oral rehydration salt + was asked to monitor mom. The sudden diarrhoea may have caused the faintness and probably the gut is also starting to work now.
    Need to monitor. If persistent, will do blood test to check salt, sugar etc + go on drip again.

    1.40 pm : mom can breathe 2 balls up high to max sometimes.

    8.00 pm : Took Omeprazole for stomach reflux ( twice a day - one in the morning + 1 at night)
    Mom is still taking it until now.
    Painkiller Dramadol ( 3 times a day) Before the end of first week at home, mom stopped taking it

    12-2-08 (Tues)
    7.35 am Dr Ramesh came + told Mom that she can be discharged today.He saw that she was recuperating well. Will see him in a month's time.

    10.00 am The wound stitches, actually 32 metal staples, are taken out carefully. A couple of them tear and bleeds. Dr Marie came to inspect them and found them to be okay as there is no pus. Dr Marie wrote the discharge summary and after waiting for a while for the medicine, we took mom home before noon time.