Murdani Abdullah

Environmental risk factors in inflammatory bowel disease: a population-based case-control study in Asia-Pacific.

Objective The rising incidence of inflammatory bowel disease in Asia supports the importance of environmental risk factors in disease aetiology. This prospective population-based case-control study in Asia-Pacific examined risk factors prior to patients developing IBD. Design 442 incident cases (186 Crohns disease (CD); 256 UC; 374 Asians) diagnosed between 2011 and 2013 from eight countries in Asia and Australia and 940 controls (frequency-matched by sex, age and geographical location; 789 Asians) completed an environmental factor questionnaire at diagnosis. Unconditional logistic regression models were used to estimate adjusted ORs (aOR) and 95% CIs. Results In multivariate model, being breast fed >12 months (aOR 0.10; 95% CI 0.04 to 0.30), antibiotic use (aOR 0.19; 0.07 to 0.52), having dogs (aOR 0.54; 0.35 to 0.83), daily tea consumption (aOR 0.62; 0.43 to 0.91) and daily physical activity (aOR 0.58; 0.35 to 0.96) decreased the odds for CD in Asians. In UC, being breast fed >12 months (aOR 0.16; 0.08 to 0.31), antibiotic use (aOR 0.48; 0.27 to 0.87), daily tea (aOR 0.63; 0.46 to 0.86) or coffee consumption (aOR 0.51; 0.36 to 0.72), presence of hot water tap (aOR 0.65; 0.46 to 0.91) and flush toilet in childhood (aOR 0.71; 0.51 to 0.98) were protective for UC development whereas ex-smoking (aOR 2.02; 1.22 to 3.35) increased the risk of UC. Conclusions This first population-based study of IBD risk factors in Asia-Pacific supports the importance of childhood immunological, hygiene and dietary factors in the development of IBD, suggesting that markers of altered intestinal microbiota may modulate risk of IBD later in life.

Irritable Bowel Syndrome: Diagnosis and Treatment

Irritable bowel syndrome (IBS) is the most common functional disorder of the gastrointestinal tract. As a result of the lack of specific diagnostic testing and absence of circumscribed biology markers of the disease, its diagnosis is based on a myriad of symptoms. The term irritable bowel syndrome was probably first coined in 1944 by Peters and Bargen. In 1849, Cumming described the clinical manifestations of Irritable Bowel Syndrome. Irritable bowel syndrome is defined on the basis of the recently modified Rome criteria as the presence of at least 12 weeks (not necessarily consecutive) of abdominal discomfort or pain in the preceding 12 months that cannot be explained by structural or biochemical abnormalities, and that has at least two of the following three features: pain relieved with defecation, an onset associated with a change in the frequency of bowel movements (diarrhea or constipation), or an onset associated with a change in form of stool (loose, watery, or pellet-like). The syndrome can be divided into three subcategories according to the Modified Rome criteria II; those with a predominant symptom of diarrhea, constipation, or constipation alternating with diarrhea. There are several criteria for irritable bowel syndrome, one of which is the Manning criteria, applied in many epidemiological and clinical studies to identify irritable bowel syndrome. However, many investigators disagree with this criteria due to a seemingly poor validity in men. In an attempt to bring order to the specialty, consensus-based approach is adopted by a group of international experts, which led to the development of the Rome criteria for irritable bowel syndrome (Table 1). Extra-intestinal symptoms, including headache, backache, urinary and gynecologic symptoms, and fatigue, are more common in the constipation-predominant subgroup.

Early Course of Inflammatory Bowel Disease in a Population-Based Inception Cohort Study From 8 Countries in Asia and Australia

BACKGROUND & AIMS The incidence of inflammatory bowel disease (IBD) is increasing in Asia, but little is known about disease progression in this region. The Asia-Pacific Crohns and Colitis Epidemiology Study was initiated in 2011, enrolling subjects from 8 countries in Asia (China, Hong Kong, Indonesia, Sri Lanka, Macau, Malaysia, Singapore, and Thailand) and Australia. We present data from this ongoing study. METHODS We collected data on 413 patients diagnosed with IBD (222 with ulcerative colitis [UC], 181 with Crohns disease [CD], 10 with IBD unclassified; median age, 37 y) from 2011 through 2013. We analyzed the disease course and severity and mortality. Risks for medical and surgical therapies were assessed using Kaplan-Meier analysis. RESULTS The cumulative probability that CD would change from inflammatory to stricturing or penetrating disease was 19.6%. The cumulative probabilities for use of immunosuppressants or anti-tumor necrosis factor agents were 58.9% and 12.0% for patients with CD, and 12.7% and 0.9% for patients with UC, respectively. Perianal CD was associated with an increased risk of anti-tumor necrosis factor therapy within 1 year of its diagnosis (hazard ratio, 2.97; 95% confidence interval, 1.09-8.09). The cumulative probabilities for surgery 1 year after diagnosis were 9.1% for patients with CD and 0.9% for patients with UC. Patients with CD and penetrating disease had a 7-fold increase for risk of surgery, compared with patients with inflammatory disease (hazard ratio, 7.67; 95% confidence interval, 3.93-14.96). The overall mortality for patients with IBD was 0.7%. CONCLUSIONS In a prospective population-based study, we found that the early course of disease in patients with IBD in Asia was comparable with that of the West. Patients with CD frequently progress to complicated disease and have accelerated use of immunosuppressants. Few patients with early stage UC undergo surgery in Asia. Increasing our understanding of IBD progression in different populations can help optimize therapy and improve outcomes.

Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool

Chronic constipation (CC) may impact on quality of life. There is substantial patient dissatisfaction; possible reasons are failure to recognize underlying constipation, inappropriate dietary advice and inadequate treatment. The aim of these practical guidelines intended for primary care physicians, and which are based on Asian perspectives, is to provide an approach to CC that is relevant to the existing health-care infrastructure. Physicians should not rely on infrequent bowel movements to diagnose CC as many patients have one or more bowel movement a day. More commonly, patients present with hard stool, straining, incomplete feeling, bloating and other dyspeptic symptoms. Physicians should consider CC in these situations and when patients are found to use laxative containing supplements. In the absence of alarm features physicians may start with a 2-4 week therapeutic trial of available pharmacological agents including osmotic, stimulant and enterokinetic agents. Where safe to do so, physicians should consider regular (as opposed to on demand dosing), combination treatment and continuous treatment for at least 4 weeks. If patients do not achieve satisfactory response, they should be referred to tertiary centers for physiological evaluation of colonic transit and pelvic floor function. Surgical referral is a last resort, which should be considered only after a thorough physiological and psychological evaluation.

Development, Translation and Validation of Enhanced Asian Rome III Questionnaires for Diagnosis of Functional Bowel Diseases in Major Asian Languages: A Rome Foundation-Asian Neurogastroenterology and Motility Association Working Team Report

Background/Aims The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Rome III criteria. Methods After EAR3Q was developed by Asian experts by consensus, it was translated into Chinese, Hindi-Telugu, Indonesian, Korean, and Thai, following Rome Foundation guidelines; these were then validated on native subjects (healthy [n = 60], and patients with irritable bowel syndrome [n = 59], functional dyspepsia [n = 53] and functional constipation [n = 61]) diagnosed by clinicians using Rome III criteria, negative alarm features and investigations. Results Experts noted words for constipation, bloating, fullness and heartburn, posed difficulty. The English back-translated questionnaires demonstrated concordance with the original EAR3Q. Sensitivity and specificity of the questionnaires were high enough to diagnose respective functional gastrointestinal disorders (gold standard: clinical diagnoses) in most except Korean and Indonesian languages. Questionnaires often uncovered overlapping functional gastrointestinal disorders. Test-retest agreement (kappa) values of the translated questionnaires were high (0.700–1.000) except in Korean (0.300–0.500) and Indonesian (0.100–0.400) languages at the initial and 2-week follow-up visit. Conclusions Though Chinese, Hindi and Telugu translations were performed well, Korean and Indonesian versions were not. Questionnaires often uncovered overlapping FGIDs, which were quite common.

Rome foundation Asian working team report: Real world treatment experience of Asian patients with functional bowel disorders

Information on real world treatment experiences of patients with functional bowel disorders is lacking from Asia. This study aimed to describe the medication exposure and treatment satisfaction of patients presenting to gastroenterology clinics across a sampling of Asian cities.

Rome Foundation-Asian working team report: Asian functional gastrointestinal disorder symptom clusters

Objective Functional gastrointestinal disorders (FGIDs) are diagnosed by the presence of a characteristic set of symptoms. However, the current criteria-based diagnostic approach is to some extent subjective and largely derived from observations in English-speaking Western patients. We aimed to identify latent symptom clusters in Asian patients with FGID. Design 1805 consecutive unselected patients with FGID who presented for primary or secondary care to 11 centres across Asia completed a cultural and linguistic adaptation of the Rome III Diagnostic Questionnaire that was translated to the local languages. Principal components factor analysis with varimax rotation was used to identify symptom clusters. Results Nine symptom clusters were identified, consisting of two oesophageal factors (F6: globus, odynophagia and dysphagia; F9: chest pain and heartburn), two gastroduodenal factors (F5: bloating, fullness, belching and flatulence; F8 regurgitation, nausea and vomiting), three bowel factors (F2: abdominal pain and diarrhoea; F3: meal-related bowel symptoms; F7: upper abdominal pain and constipation) and two anorectal factors (F1: anorectal pain and constipation; F4: diarrhoea, urgency and incontinence). Conclusion We found that the broad categorisation used both in clinical practice and in the Rome system, that is, broad anatomical divisions, and certain diagnoses with long historical records, that is, IBS with diarrhoea, and chronic constipation, are still valid in our Asian societies. In addition, we found a bowel symptom cluster with meal trigger and a gas cluster that suggests a different emphasis in our populations. Future studies to compare a non-Asian cohort and to match to putative pathophysiology will help to verify our findings.

The Causes of Upper Gastrointestinal Bleeding in the National Referral Hospital: Evaluation on Upper Gastrointestinal Tract Endoscopic Result in Five Years Period

Backgrounds: Gastrointestinal bleeding such as hematemesis or melena are common conditions in clinical practice and endoscopic service. The mortality rate due to gastrointestinal bleeding is relatively high. In this study, we evaluate the causes of hematemesis melena for the last 5 years and the factors associated with the bleeding. Methods: The study was done retrospectively. We obtained data from medical record of patients that performed endoscopy of upper gastrointestinal tract in Division of Gastroenterology, Department of Internal medicine, Cipto Mangunkusumo hospital (Jakarta, Indonesia) during the period of 2001 to 2005. Results: Of 4.154 patients who underwent upper gastrointestinal tract endoscopy from 2001 to 2005, we found that 837 patients (20.1%) were due to upper gastrointestinal bleeding. They were 552 male (65.9%) and 285 female patients (34.1%). Mean age of male patients was 52.7 ± 15.82 years, while for female patients was 54.46 ± 17.6 years. Of 837 patients who came due to hematemesis were 150 patients (17.9%), melena were 310 patients (37.8%), both melena and hematemesis were 371 patients (44.3%), 557 cases (66.5 %) due to non varices. Endoscopic results showed that 280 cases (33.4%) were due to esophageal varices. In general, this study had demonstrated that esophageal varices was the most frequent cause of upper gastrointestinal bleeding. We found 229 cases of esophageal varices were coincidence with portal hypertensive gastropathy. While ulcer was found in 225 cases (26.9%) and most of them were gastric ulcer (51.1%). Of gastrointestinal bleeding caused by esophageal varices, most were grade III in 138 cases (49.3%). The incidence of bleeding of bleeding were found more frequently in patients age group of 40 - 60 years (389 cases; 46.5%), > 60 years (305 cases; 36.2%), 60 years, most were caused by ulcer (37.4%). In this study, we also found that cancer as the cause of gastrointestinal bleeding in 26 cases (3.1%). Gastrointestinal cancer comprised of gastric cancer in 15 cases (57.7%), duodenal cancer in 7 cases (26.9%), and esophageal cancer in 4 patients (15.4%). Conclusion: The most frequent cause of upper gastrointestinal bleeding was esophageal varices and usually had reached stage III. The non variceal cause of bleeding was gastric cancer. Upper gastrointestinal malignancy was also found to be the etiology of bleeding in this study. Keywords : upper gastrointestinal bleeding, endoscopy

Ramadan Fasting Decreases Body Fat but Not Protein Mass.

Background: Many studies have shown various results regarding the effects of Ramadan fasting on weight and body composition in healthy individuals. Objectives: This study aimed to evaluate the effect of Ramadan fasting on body composition in healthy Indonesian medical staff. Objectives: In this study, we examined the influence of Ramadan fasting on body composition in healthy medical staff. Patients and Methods: The longitudinal study was performed during and after Ramadan fasting in 2013 (August to October). Fourty-three medical staff members (physicians, nurses and nutritionists) at the Internal Medicine Ward of the Dr. Cipto Mangunkusumo General Hospital were measured to compare their calorie intake, weight, body mass index, waist-to-hip ratio (WHR), and body composition, including body fat, protein, minerals and water, on the first and 28th days of Ramadan and also 4-5 weeks after Ramadan fasting. Measurements were obtained for all 43 subjects on the 28th day of Ramadan, but they were obtained for only 25 subjects 4 - 5 weeks after Ramadan. Results: By the 28th day of Ramadan, it was found that the body weight, BMI, body fat, water and mineral measures had decreased significantly (-0.874 ± 0.859 kg, P < 0.001; -0.36 ± 0.371 kg/m2, P < 0.001; -0.484 ± 0.597 kg, P < 0.001; -0.293 ± 0.486 kg, P = 0.001; -0.054 ± 0.059 kg, P < 0.001, respectively). Protein body mass and calorie intake did not significantly change (-0.049 ± 0.170 kg, P = 0.561; 12.94 ± 760.608 Kcal, P = 0.082 respectively). By 4 - 5 weeks after Ramadan, body weight and composition had returned to the same levels as on the first day of Ramadan. Conclusions: Ramadan fasting resulted in weight loss even it was only a temporary effect, as the weight was quickly regained within one month after fasting. The catabolism catabolic state, which is related to protein loss, was not triggered during Ramadan fasting. Further research is needed to evaluate the effects of weight loss during Ramadan fasting in healthy individuals.

RECENT PROGRESS IN ENDOSCOPY-BASED DIAGNOSIS OF HELICOBACTER PYLORI INFECTION

Numerous invasive and non‐invasive tests are available in the detection of Helicobacter pylori. Endoscopy‐based tests that include rapid urease test, histological examination and culture are important generally in the assessment of H. pylori status before eradication therapy. Recently, several new endoscopy‐based diagnostic methods have been developed aiming at rapid and accurate detection of the organisms. It would be possible to diagnose H. pylori infection in treated patients by using these new highly sensitive tests. Although the diagnosis of H. pylori infection itself is possible by using non‐invasive diagnostic tests, endoscopy‐based tests provide not only the diagnosis of the organisms, but also the exclusive information such as treatment indications and the susceptibility for the antimicrobial drugs. Recently, new triple therapy including clarithromycin has been widely performed in Japan. Along with an increase in the prevalence of the antibiotic‐resistant strains, culture may become a more important diagnostic method in the future. The inappropriate application of the tests may increase the potential risk of the misdiagnosis and the treatment failures. The diagnostic method should be selected by taking into account the circumstances in which a diagnosis is to be performed.