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.