Punch to the gut

The Star Malaysia - Star2 - - Digestive Health & You - By IAN JEROME LEONG

VERY of­ten, peo­ple who are ex­pe­ri­enc­ing stom­ach cramps, fa­tigue and fever may brush off the whole or­deal and as­sume the cause for such symp­toms to be a mere stom­ach bug.

How­ever, when the in­tense pain per­sists and other symp­toms in­clude wa­tery or bloody stools, re­duced ap­petite and weight loss, there is a pos­si­bil­ity that you have in­flam­ma­tory bowel dis­ease (IBD).

IBD was the fo­cus of last week’s World Di­ges­tive Health Day, an an­nual ini­tia­tive by the World Gas­troen­terol­ogy Or­gan­i­sa­tion (WGO) to in­crease the gen­eral aware­ness of spe­cific di­ges­tive disor­ders, in­clud­ing their re­lated re­search, pre­ven­tion and ther­apy. This year’s cam­paign was aimed at pro­vid­ing gas­troen­terol­o­gists, pa­tients, health­care providers and the gen­eral public with the rel­e­vant ba­sic and clin­i­cal knowl­edge sur­round­ing IBD. A cru­cial fac­tor about IBD is that there is still a lack of un­der­stand­ing or in­for­ma­tion about the dis­ease’s man­ner of de­vel­op­ment in­side the hu­man body within the med­i­cal fra­ter­nity. Sci­en­tists and doc­tors have yet to pin­point the def­i­nite causes of IBD and the med­i­ca­tions cur­rently ribed to IBD pa­tients are her­a­pies to dampen the nt im­mune re­sponse or ess the in­flam­ma­tion. e good news is that the ber of IBD cases re­mains ively low in Malaysia and e are ther­a­pies avail­able. ow­ever, this does not an that Malaysians should e the dis­ease lightly as it reatly im­pede daily life us­ing wa­ter and salt anaemia, de­hy­dra­tion, e weight loss and bly life-threat­en­ing li­ca­tions in the long run.

Un­der­stand­ing the threat

The good news is that the num­ber of IBD cases re­mains rel­a­tively low in Malaysia and there are ther­a­pies avail­able.

an be sep­a­rated into two sease cat­e­gories – dis­ease (CD) that af­fects and ul­cer­a­tive col­i­tis can af­fect any part of the ys­tem.

Both con­di­tions have over­lap­ping and dis­tinct clin­i­cal and patho­log­i­cal fea­tures that are a re­sult of an ab­nor­mal im­muno­log­i­cal re­sponse whereby the pa­tient's white blood cells and other in­flam­ma­tory cells at­tack the gas­troin­testi­nal tract, lead­ing to pro­longed, un­con­trolled in­flam­ma­tion and ul­cer­a­tion.

“In se­vere case is par­tic­u­larly de­bili an greatly re­stricts one lyl sa s Prof Dr Lee Yeong Yeh, pro­fes­sor of medicine and con­sul­tant of gas­troen­terol­ogy at Univer­siti Sains Malaysia.

“Al­though the symp­toms in milder cases may sub­side, they can re­cur and progress to be­come more se­vere if left un­treated.

“Se­vere cases may re­quire spe­cialised treat­ment in the form of bi­o­log­ics man­aged by a gas­troen­terol­o­gist. Those of higher sever­ity may need surgery.”

Prof Lee, who also holds the po­si­tion of sci­ence lead­er­ship chair of the Acad­emy of Sciences Malaysa’s Young Sci­en­tist Net­work, says the com­mon symp­toms in­clude abdominal pain, wa­tery or bloody stools, fever, weight loss and feel­ing eas­ily tired while less com­mon ones in­clude joint and skin prob­lems.

World Di­ges­tive Health Day 2017 chair Dr Charles Bern­stein wrote in his in­tro­duc­tion of IBD on WGO’s web­site: “The patho­gen­e­sis of IBD is in­com­pletely un­der­stood. As IBD is in­creas­ingly a world­wide dis­ease, one chal­lenge will be to de­ter­mine if the ther­a­pies proven to be ef­fec­tive in one pop­u­la­tion will be com­pa­ra­bly ef­fec­tive in an­other.

“An­other chal­lenge will be to fa­cil­i­tate ac­cess to novel ex­pen­sive ther­a­pies in lesser priv­i­leged coun­tries.”

Though the cause of IBD is un­known, ge­netic and en­vi­ron­men­tal fac­tors are be­lieved to play a role in trig­ger­ing the dis­ease.

Ac­cord­ing to a 2015 ar­ti­cle ti­tled Man­age­ment of IBD in Malaysia pub­lished in the IBD Re­search jour­nal, the preva­lence of in­flam­ma­tory bowel dis­ease (IBD), ul­cer­a­tive col­i­tis (UC) and Crohn's dis­ease (CD) in the coun­try was at 9.24, 6.67 and 2.17 per 100,000 per­sons re­spec­tively.

Hence, the es­ti­mated num­ber of peo­ple with IBD in Malaysia is be­tween 2,000 and 3,000, with a larger num­ber of cases among the In­dian eth­nic com­mu­nity and the ma­jor­ity of all pa­tients fall­ing be­low the age of 30.

While it is good that many peo­ple do not live with IBD in Malaysia, this in it­self can be dis­cour­ag­ing for pa­tients.

The jour­nal ar­ti­cle states that there is a lack of ex­pe­ri­ence in the use of bi­o­log­ics to treat IBD, lead­ing to the overuse of steroids.

In ad­di­tion, it claims that sur­gi­cal ex­per­tise is lim­ited as there are few col­orec­tal sur­geons with spe­cific IBD train­ing or ex­pe­ri­ence.

Worse still is when pa­tients of IBD re­quire surgery but ex­hibit side ef­fects of long-term steroid use and nu­tri­tional de­fi­cien­cies, fur­ther com­pro­mis­ing sur­gi­cal suc­cess.

Th­ese find­ings mir­ror an­other 2015 ar­ti­cle, Chronic at­tacks on the bowel, which states that due to the in­fre­quent num­ber of IBD cases in the coun­try, some di­ag­noses were de­layed by doc­tors or, worse, mis­taken for other con­di­tions such as ir­ri­ta­ble bowel syn­drome, haem­or­rhoids or even can­cer due to the over­lap­ping symp­toms.

Prof Lee agrees that aware­ness of the dis­ease is gen­er­ally low among health­care providers and IBD can be dif­fi­cult to dis­tin­guish from can­cers based on symp­toms alone.

How­ever, he adds, “Sub­se­quent in­ves­ti­ga­tions in­clud­ing colonoscopy should be able to differentiate be­tween IBD and can­cer, and if there is sus­pi­cion of ei­ther con­di­tion, it is best to re­fer to a gas­troen­terol­o­gist or spe­cial­ist in bowel disor­ders.”

De­fus­ing the sit­u­a­tion

In the United King­dom where the preva­lence of IBD is much

Fif­teen per cent of pa­tients with UC in the United King­dom were un­able to work after five to 10 years liv­ing with the dis­ease while pa­tients with mod­er­ate to se­vere UC faced a 30% in­creased risk of work im­pair­ment com­pared to those without.

hig – peo­ple or 400 pa­tients per 100,000 of the pop­u­la­tion – the IBD Stan­dards Group (a UK group made up of var­i­ous di­ges­tive, pae­di­atric and gas­troen­terol­ogy as­so­ci­a­tions and so­ci­eties) re­ported that up to 85% of IBD pa­tients re­quired hos­pi­tal­i­sa­tion and up to 70% of pa­tients with CD re­quired surgery within five years of di­ag­no­sis.

Fif­teen per cent of pa­tients with UC in the UK were un­able to work after five to 10 years liv­ing with the dis­ease while pa­tients with mod­er­ate to se­vere UC faced a 30% in­creased risk of work im­pair­ment com­pared to those wit .

One would be for­given for won­der­ing if Malaysia too will face such a dire sit­u­a­tion, given the ris­ing num­ber of IBD cases lo­cally and how the sit­u­a­tion can take a toll on an al­ready stressed na­tional health­care sys­tem.

For­tu­nately, Malaysia’s IBD num­bers are still among the low­est glob­ally. In ad­di­tion, Prof Lee be­lieves that Malaysia has the right ther­a­pies in place, whether through bi­o­log­ics or surgery. How­ever, pa­tients need to have the right di­ag­no­sis early. While the aware­ness of IBD may still be low in Malaysia, the Malaysian med­i­cal field is start­ing to pay more at­ten­tion to un­der­stand­ing the dis­ease.

The es­tab­lish­ment of an IBD in­ter­est group, Per­sat­uan Crohn dan Koli­tis Malaysia, as well as col­lab­o­ra­tions with in­ter­na­tional agen­cies such as the Euro­pean Crohn’s and Col­i­tis Or­gan­i­sa­tion and Asian Or­ga­ni­za­tion for Crohn’s & Col­i­tis are steps in the right di­rec­tion, but the med­i­cal fra­ter­nity also needs to en­sure Malaysia con­tin­ues to have a con­trol of the sit­u­a­tion.

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