MSGH Update in Gastroenterology & Hepatology – · PDF fileProf Dato’ P Kandasami...

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– MSGH Update in Gastroenterology & Hepatology –

Message From The President of Malaysian Society of 2 Gastroenterology & Hepatology

Message From The Scientific Chairman And 3 – 4 Scientific Co-Chairman

Daily Programme 5 – 6

Faculty Bio-Data 7 – 13

Function Rooms And Trade Display 14

Acknowledgements 15

Abstracts 16 – 26

President Dr Ramesh Gurunathan

President Elect Prof Sanjiv Mahadeva

Immediate Past President Dr L Sanker V

Hon Secretary Dr Ong Tze Zen

Hon Treasurer Dr Sheikh Anwar

Committee Members Dr Akhtar Qureshi Dato’ Dr Mazlam Zawawi Dr Ooi Eng Keat Dr Soon Su Yang Dato’ Dr Tan Huck Joo Prof Dato’ Goh Khean Lee Datuk Dr Jayaram Menon Prof Dato’ P Kandasami

Contents

MSGH Committee2011 – 2013

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It is with great pleasure the Malaysian Society of Gastroenterology & Hepatology starts 2013 with this update in Kuantan, Pahang. This is the first time the MSGH is organising a one-day meeting in Kuantan. The topics discussed will be of interest to gastroenterologists, surgeons and trainees. We have excellent speakers who will present on various topics and discussions.

The MSGH hopes to continue having this event on yearly basis in the future, more for the benefit of members in the East Coast .

RAMESH GuRunATHAn

President Malaysian Society of Gastroenterology & Hepatology

Message From The President Of Malaysian Society of Gastroenterology & Hepatology

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Welcome to the MSGH Update in Gastroenterology and Hepatology in Kuantan, Pahang.

This weekend update is meant for a small audience, therefore making it more interactive. This is part of the effort of the Malaysian Society of Gastroenterology and Hepatology to organise CPD meetings in addition to the very successful regular Klang Valley meetings. We have a host of local and foreign experts who will be sharing with you, the latest developments in the field of Gastroenterology and Hepatology.

Professor Pierce Chow is a senior HPB surgeon at the Singapore General Hospital. An expert in hepatocellular carcinoma management, he is the Co-Founder of the Asia Pacific Hepatocellular Carcinoma Trials Group and has been instrumental in many multicentre trials. He will enlighten us on the latest in loco-regional therapy in HCC.

Professor Teerha Piravisuth from Thailand, was the Past President of APASL and is an international expert in the area of viral hepatitis. He has played a pivotal role in many of the Asia Pacific consensus statements for chronic hepatitis B and C and will lecture on Individualized therapy for optimizing outcomes in Chronic Hepatitis B.

Dr Charles Vu is currently the Head of Gastroenterology and Endoscopy at Tan Tock Seng Hospital, Singapore. Experienced in both interventional Endoscopy and Endoscopic Ultrasound, Dr Vu will be updating us on the management of pancreatic cysts.

Message From The Scientific Chairman And Scientific Co-Chairman

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Professor Lawrence Ho from the National University of Singapore is well known to the MSGH. An accomplished endoscopist and trainer, he is the current chair of the Asian Barrett’s Consortium and Asian Consortium in EUS. His latest ground breaking achievement is the innovation of the Master and Slave Transluminal Endoscopic Robot (MASTER), the world’s first flexible robotic endoscopic system, successfully used to perform endoscopic submucosal dissection in human subjects in 2011.

In addition, there are also many local experts, both senior and emerging stars of the future who will update us on various aspects of GI system. We hope you will have an enjoyable and a memorable meeting.

TAn HucK JOO SAnJiV MAHADEVAScientific Chairman Scientific Co-Chairman

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Programme 19th January 2013

0730 – 0750 Registration

0750 – 0800 Welcome speech by Organising ChairmanDr rAMeSh GurunAThAn

0800 – 0920 CliniCal issuesChAirperSonS: Dr Tee hoi poh Dr KhAirul AzhAr JAAFAr

Managing Patients with Non-Alcoholic Fatty Liver Disease (NAFLD) [page 16]DATo’ Dr MAzlAM zAwAwi

Intractable GERD – What is Next? [page 17]Dr MohAMeD hADzri hASMoni

Imaging of the Liver Lesion [page 18]Dr AhMAD helMy

0920 – 1040 stomaChChAirperSonS: DATo’ Dr TAn huCK Joo Dr onG Tze zen

The Role of PPIs in Functional Dyspepsia [page 19]proF Dr SAnJiv MAhADevA

Salvage Therapy for H pylori [page 20]DATo’ Dr roSeMi SAlleh

The Significance of Intestinal Metaplasia and AtrophyDr Soon Su yAnG

1040 – 1100 Tea

1100 – 1220 liverChAirperSonS: proF DATo’ MrS Kew SiAnG TonG Dr ooi enG KeAT

Treatment of Chronic Hepatitis B : Individualized Therapy for Optimizing OutcomesDr TeerhA pirAviSuTh

Loco-Regional Therapy in HCC – Current Status and Future Directions [page 21]Dr pierCe Chow

Update on Treatment of Chronic Hepatitis [page 22]ASSoC proF Dr hAMizAh rAzlAn

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Programme 19th January 2013 [cont’d]

1220 – 1400 Lunch Satellite Symposium (AstraZeneca)ChAirperSon: Dr Tee hoi poh

GERD: Practical Approaches to Diagnosis and ManagementproF lAwrenCe ho KheK yu

1400 – 1540 ColoreCtalChAirperSonS: proF AzMi MD nor ASSoC proF ShAnThi pAlAniAppAn Dr AhMAD MArDzuKi ibrAhiM

Low Rectal Cancer – Can We Spare the Patient from An Abdominoperineal Resection? [page 23]Dr AKhTAr QureShi

Surgery for Colorectal Liver MetastasisDr Jin bonG

Epidemiology of Outcome of Colorectal Cancer – The Malaysian PerspectiveDr nil AMri

Starting Biologics in Asian IBD Patients [page 24]Dr nAzri MuSTAFFA

1540 – 1720 endosCopyChAirperSonS: Dr SheiKh AnwAr Dr rAMeSh GurunAThAn Managing Pancreatic CystDr ChArleS vu Kien FonG

Advances in EUS Guided InterventionDATin Dr ShArMilA SAChiThAnAnDAn

Rescue for Fistula, Perforations and Bleeding – Spare the Surgeon!DATo’ Dr AhMAD ShuKri

Management of Biliary Strictures [page 25-26]Dr rAMAn MuThuKAruppAn

1720 Closing Remarks and Tea

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Faculty bio-Data

AHMAD HELMY Bin ABDuL KARiMDr Ahmad Helmy graduated from Universiti Sains Malaysia in 2002 and subsequently obtained his Master of Medicine (Radiology) at the same university in 2009. He then became a Fellow in neuroradiology at National Neuroscience Institute, Tan Tock Seng Hospital, Singapore in 2011. He is currently a medical lecturer and clinical radiologist in the Department of Radiology, Universiti Sains Malaysia Hospital. His special interest is neuroradiology and interventional radiology.

AHMAD SHuKRi Bin MD SALLEHDato’ Dr Ahmad Shukri graduated from the University Malaya in 1989. After his basic and postgraduate training in the Ministry of Health, Malaysia, he became a registrar in Medicine and Gastroenterology at the Royal Liverpool University Hospital and the Manchester Royal Infirmary, UK. He was also the Fellow in Gastroenterology in Endoscopy Department at the world renowned Eppendorf University Hospital, Hamburg, Germany under Prof Nib Soehendra and Prof Stefan Seewald before joining Dr John Meenan at St Thomas Hospital in London as a Fellow in Endoscopic Ultrasound. Dato’ Dr Shukri is currently the Head of Endoscopy and Consultant Gastroenterologist at Hospital Sultanah Nur

Zahirah, Kuala Terengganu. He was also the Head of Medical Department at Putrajaya Hospital in 2006 - 2008. His special interest is endoscopic intervention for closure of GI fistula, bleeding and perforation, EUS and intragastric placement for obesity.

AKHTAR QuRESHiDr Akhtar Qureshi graduated with honours from the Royal College of Surgeons in Ireland. He subsequently trained in Ireland and England completing his basic, higher and advanced surgical training. Dr Qureshi returned to Malaysia to join Universiti Kebangsaan Malaysia where he headed the colorectal unit, training local postgraduates. He subsequently moved to the International Medical University as Professor and Head of Surgery. Dr Qureshi is currently Consultant Colorectal Surgeon at the Sunway Medical Centre. He was the chairman of the national committee on colorectal cancer screening guideline consensus. He is a founding member and past-president of the Malaysian

Society of Colorectal Surgeons and has been instrumental in developing colorectal surgery as a sub-speciality in Malaysia. Dr Qureshi has an interest in both clinical surgery and research, with over 100 scientific publications on surgical issues with numerous local and international papers. He has a special interest in colorectal diseases.

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Faculty bio-Data [cont’d]

PiERcE cHOwProfessor Pierce Chow is Senior Consultant HPB Surgeon at the Singapore General Hospital and Course Director at the Duke-NUS Graduate Medical School, Singapore. He is also visiting Senior Consultant at the National Cancer Center as well as Senior Clinician Investigator with the National Medical Research Council, Singapore.

Professor Chow was the Chapter of Surgeon’s Gold Medalist at the conjoint Royal College of Surgeons of Edinburgh/M.Med (Surgery) examination in 1994 and completed a clinical fellowship in Liver Transplantation in Australia in 2000. In 1995, he won

the prestigious Young Surgeon’s Award of the Academy of Medicine, Singapore for his research into the patho-physiology of liver blood flow and regeneration. He has gone on to receive many other academic and professional awards. He has received two NMRC Research Fellowships (in 1995 and 1997) and in 2004 was conferred his PhD.

Professor Chow has published extensively on hepato-biliary cancers and gastrointestinal stromal tumours and carried out both preclinical and clinical research on brachytherapy in HCC and pancreatic cancers. He has more than 170 scientific papers, books and book chapters and advises both the government and the industry on biomedical research. He also has established a strong track record in experimental oncology and in clinical trials. He co-founded the Asia-Pacific Hepatocellular Carcinoma Trials Group in 1997 and has been the protocol chair of five multi-national trials. Currently, Professor Chow is the protocol chair of a 26-center investigator-initiated phase III trial that compares a selective internal radiation device (SIRsphere®) against molecular targeted therapy (sorafenib) in locally advanced HCC. The trial is funded jointly by both the NMRC and the industry and is conducted under the auspices of the Asia-Pacific Hepatocellular Carcinoma (AHCC) trials group. In 2012 he was conferred the National Outstanding Clinician-Scientist Award for his research on hepatocellular carcinoma.

HAMiZAH RAZLAnDr Hamizah Razlan is currently the Head of Gastroenterology and Hepatology, and Deputy Head of Medical Department, Universiti Kebangsaan Malaysia Medical Centre. She is also Associate Professor at the Department of Medicine, UKMMC. Dr Hamizah received her undergraduate training in Medicine at Glasgow University, Scotland, UK before returning to Malaysia to complete her Master of Medicine at the Universiti Kebangsaan Malaysia. She then did her fellowship in Gastroenterology at the UKMMC, Hospital Selayang and UMMC. Her special interest is in liver diseases.

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Jin BOnGDr Bong Jan Jin graduated from the University of Leeds in 1996, and later in 2004, was awarded the degree of Doctorate of Medicine (MD) for his research thesis. He received specialist surgical training at the prestigious Northwest Thames (London Deanery) Programme. After completing his specialist training in general and hepato-biliary surgery, he continued his fellowship training at the Hammersmith Hospital, London.

Dr Bong was appointed Associate Professor (Academic) at the Universiti Kebangsaan Malaysia in 2009. He is currently consultant hepatobiliary surgeon at the Sunway Medical Centre. Dr Bong has

published 23 papers in peer-reviewed journals, many of which were of original research in high-impact journals. Dr Bong specialized in complex hepato-biliary and pancreatic surgery and established the first laparoscopic hepatectomy program at HUKM.

LAwREncE HO KHEK YuProfessor Lawrence Ho is currently Professor of Medicine; Chair, University Medicine Cluster; Head, Department of Medicine; Head, Department of Gastroenterology & Hepatology and Clinical Director of the Endoscopy Centre; National University Health System, Singapore. He graduated with first class honours from the University of Sydney, and undertook his training in therapeutic endoscopy and endoscopic ultrasound at the Brigham and Women’s Hospital, and Hospital of the University of Pennsylvania, USA. His major research interest relates to innovative GI endoscopic technology. He has held four patents in endotech products. As co-inventor for the ground-breaking technology of the

Master and Slave Transluminal Endoscopic Robot (MASTER), he was part of the team who developed the world’s first flexible robotic endoscopy system, which was successfully used to perform endoscopic submucosal dissection in human patients in 2011.

In collaboration with Harvard University & Genomic Institute of Singapore, he and the team have made important strides in the cloning of oesophageal stem cells from patients with Barrett’s oesophagus. This represents a fundamental breakthrough for understanding the nature of intestinal metaplasia and its role in the origins of upper GI cancers. In pursuit of bringing together regional experts with collaborative research in Barrett’s oesophagus and endoscopic ultrasound, Professor Ho is also the current Chair of the Asian Barett’s Consortium and the Asian Consortium in EUS. He has published more than 130 SCI papers, more than 10 book chapters, and co-edited two books. His other academic achievements include being the Associate Editor of Digestive Endoscopy, and Editorial Board Members of GUT, Journal of Gastroenterology and Hepatology, and many others. He was President of Gastroenterological Society of Singapore in 2005-2006. He delivered the JGH Foundation Emerging Leadership Lecture in APDW2010. In recognition of his pursuit of innovation in medicine, he was awarded the Inaugural National University Health System Leadership Award – Clinical Innovator (Individual) Award in 2011.

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MOHAMED HADZRi HASMOniDr Mohamed Hadzri graduated from Cardiff University in 1999 and trained in Internal Medicine in Hospital Universiti Kebangsaan Malaysia with MMed in 2006. He then underwent his Fellowship training in Gastroenterology in the Ministry of Health, Malaysia before pursuing his further training at the Kinki University Faculty of Medicine, Osaka-sayama, Osaka, Japan. He was the winner of the APAGE/JGHF Clinician Scientist Training Fellowship Award 2011 where he spent a year as a fellow in Gastroenterology at the Royal Adelaide Hospital, Australia. Dr Hadzri is currently Associate Professor at the Department of Internal Medicine, International Islamic University Malaysia.

MAZLAM MOHD ZAwAwiDato’ Dr Mazlam Mohd Zawawi is a Consultant Gastroenterologist in KPJ Ampang Puteri Specialist Hospital, Ampang, Selangor. He received his undergraduate medical education from the Royal College of Surgeons in Ireland. He then completed his internship in Hospital Kuala Lumpur and subsequently trained in Internal Medicine and Gastroenterology in Universiti Kebangsaan Malaysia based at Hospital Kuala Lumpur. He became a Research Fellow, supervised by Professor HJF Hodgson, Professor of Gastroenterology, Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London in 1989 to 1992, leading to an MD degree. He was formerly head of Department

of Medicine and Gastroenterology at Hospital UKM. Dato’ Dr Mazlam is a committee member and was a past president of the Malaysian Society of Gastroenterology and Hepatology.


nAZRi MuSTAffADr Nazri Mustaffa graduated from the University of Adelaide in 2000 and obtained his Master of Medicine at Universiti Sains Malaysia in 2007. He is currently a senior lecturer at the Department of Medicine, Universiti Sains Malaysia. He is also a PhD Scholar at the Centenary Institute of Cancer Medicine and Cell Biology, University of Sydney, Australia and a postgraduate Research Scholar, Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia. Dr Nazri has wide research interests, ranging from gastroenterology, cardiovascular disease, type 2 diabetes mellitus, lipids and phamacogenetics and genomic medicine.

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RAMAn MuTHuKARuPPAn cHETTiARDr Raman Muthukaruppan graduated from Mangalore University, India and received his Master of Internal Medicine training from University of Malaya. He then underwent his Fellowship training in Gastroenterology and Hepatology under the Ministry of Health, Malaysia. He also spent one year in Advanced GI endoscopy at the Royal Prince Alfred Hospital, Sydney, Australia. Dr Raman is currently a Consultant Physician and Gastroenterologist at Queen Elizabeth Hospital, Kota Kinabalu, Sabah. He is also the Head of Gastroenterology Unit at the Hospital. His special interest is in therapeutic endoscopy, pancreatobiliary diseases and GIST tumours.

ROSEMi SALLEHDato’ Dr Rosemi Salleh is Consultant Physician and Gastroenterologist at Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan. He graduated in 1984 from University Kebangsaan Malaysia and completed his MMed in Internal Medicine in 1992. This was followed by a Fellowship in Gastroenterology at the Ministry of Health. He has been a trainer for the MOH Fellowship programme for many years. His special interest is in GI Therapeutic endoscopy.

niL AMRi Bin MOHAMED KAMiLDr Nil Amri is currently Consultant Colorectal Surgeon at Hospital Sultanah Bahiyah, Alor Setar, Kedah. He graduated from the University of Malaya followed by Master of Surgery at Universiti Kebangsaan Malaysia. He underwent his colorectal surgery fellowship training in the Ministry of Health before doing his clinical fellowship in colorectal surgery at the Department of Surgery, National University Hospital and subsequently in the Department of Surgery, Queen Elizabeth Hospital, Woodville, South Australia. Dr Nil Amri is also an honorary lecturer at the Asian Institute of Medicine, Science & Technology.

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SHARMiLA SAcHiTHAnAnDAnDatin Dr Sharmila Sachithanandan is Consultant Gastroenterologist at the Sime Darby Medical Centre, Petaling Jaya. She was formerly Head of Endoscopy at the Selayang Hospital, Selangor. Datin Dr Sharmila graduated from the Royal College of Surgeons in Ireland. She has a special interest in therapeutic Hepatobiliary Endoscopy and Endoscopic Ultrasound (EUS). Her expertise in the field of EUS is recognised regionally and internationally, with several invitations as faculty to various EUS-based workshops in both Asia and Europe.

SAnJiV MAHADEVAProfessor Sanjiv Mahadeva is currently Professor of Medicine at the University Malaya Medical Centre. A graduate of University of New Castle, Prof Sanjiv received his postgraduate training in Internal Medicine and Gastroenterology in Leeds, UK. His work on functional dyspepsia lead to an MD degree from University of Leeds, UK. One of the most prolific researchers in Malaysia, Professor Sanjiv has published widely. He is currently the President-Elect of the Malaysian Society of Gastroenterology and Hepatology, and immediate past President of the Parenteral Nutrition Society of Malaysia.

SOOn Su YAnGDr Soon Su Yang graduated from the University of Nottingham in 1992. He then received his basic and higher training in Internal Medicine and Gastroenterology in some of the best hospitals in UK, including the King’s College Hospital, London, Guy’s and the St Thomas Hospital, London. He was then appointed Consultant Gastroenterologist at the Kuching Specialist Hospital and Sarawak General Hospital. He is a committee member of the Malaysian Society of Gastroenterology and Hepatology. His research interest is in inflammatory bowel disease.

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cHARLES Vu KiEn fOnGDr Charles Vu is currently the Head and Senior Consultant, Department of Gastroenterology and Hepatology and Assistant Chairman of Medical Board at Tan Tock Seng Hospital, Singapore. Dr Vu graduated from Monash University and completed his post-graduate training in Medicine and Gastroenterology at Monash Medical Centre. He then became a Clinical Fellow at the Guys’ & St Thomas’ Hospitals, London, UK. Dr Vu is currently adjunct Assistant Professor at National University Hospital, Singapore. He is also a Board member of Chapter of Gastroenterologists, College of Physicians, and a member of Gastroenterology Residency Advisory Committee. An accomplished interventional

endoscopist, Dr Vu has published widely. Along with J. Meenan, they have produced some award winning DVD for EUS training.

TEERHA PiRAViSuTHDr Teerha Piratvisuth is Associate Professor of Medicine at the Prince of Songkla University, Hat Yai, Thailand. He completed his medical degree at the Prince of Songkla University in 1985. During 1993 – 1994 he studied as a Clinical Fellow in hepatology at King’s College School of Medicine and Dentistry in London, UK. In 1995 he moved to the US, where he spent a further year as a Clinical Fellow in hepatology and endoscopy at the University Texas, Houston Medical School. He also currently holds the positions of Vice Dean at Prince of Songkla University and Director of the NKC Institute of Gastroenterology and Hepatology. Dr Piratvisuth is President of the Liver Society of Thailand. He was

the President of APASL 2011. Dr Piratvisuth is a member of the Asia-Pacific Management of Chronic Hepatitis B Advisory Board, the Working Party for the APASL consensus on Management of Chronic Hepatitis B, and the Working Party for the APASL consensus on Management of Chronic Hepatitis C. Dr Piratvisuth has an extensive publication history and is on the editorial board of Hepatology International and is a reviewer for the Journal of Gastroenterology and Hepatology, the Journal of Alimentary Pharmacology and Therapeutics, the Journal of Hepatology, Hepatology, Liver International and the Journal of Viral Hepatitis.

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SILK

Conference Hall

ORGANZA CASHMERE

EndosurgerySdn Bhd

Eisai (M)Sdn Bhd

Nycomed:a TakedaCompany

Janssen

AstraZeneca

Function rooms And Trade Display

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The Organising Committee of the MSGH update in Gastroenterology & Hepatology

would like to express its grateful thanks to the following for their contributions and support:

Invited Speakers and Chairpersons

Ministry of Health Malaysia

AstraZeneca Sdn Bhd

Novartis

Janssen

Eisai (M) Sdn Bhd

Endosurgery Sdn Bhd

Nycomed: a Takeda Company

Bayer Healthcare Pharmaceuticals

Endodynamics

Acknowledgements

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Managing patients with non-alcoholic fatty liver disease (nafld)

Mazlam Mohd ZawawiKPJ Ampang Puteri Specialist Hospital (APSH), Ampang, Selangor, Malaysia

Non-alcoholic fatty liver disease (NAFLD) is an increasingly important condition that may progress to cirrhosis, hepatocellular carcinoma (HCC) and liver failure. Non-alcoholic fatty liver disease comprises of a wide spectrum of liver damage, which ranges from simple and uncomplicated steatosis, to steatohepatitis to advanced fibrosis and cirrhosis. Histologically non-alcoholic fatty liver disease (NAFLD) is categorized into non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis(NASH). Non-alcoholic fatty liver (NAFL) is defined as the presence of hepatic steatosis with no eividence of hepatocellular injury in the form of ballooning of hepatocytes. Non-alcoholic steatohepatitis (NASH) is defined as the presence of hepatic steatosis and inflammation with hepatocyte injury (ballooning) with or without fibrosis.

Metabolic risk factors such as obesity, type 2 (non-insulin dependent) diabetes mellitus and dyslipidaemia, alone or in combination are associated with NAFLD. However many patients who had none of these co-morbid risk factors are increasingly diagnosed to have NAFLD.

Lifestyle Intervention is the recommended initial therapy for all patients with NAFLD. Management of patients with NAFLD should focus on correction of the underlying associated conditions. In patients with diabetes mellitus or dyslipidaemia good metabolic control is recommended. Patients with NAFLD and elevated liver enzymes are not at a higher risk of hepatotoxicity from statin use for the treatment of hypercholesterolaemia.

Several pharmacological therapies directed specifically at the liver disease have been reported. Insulin-sensitizer drug, metformin is not recommended as a specific treatment for liver disease in adults with NASH. Pioglitazone can be used to treat steatohepatitis in patients with biopsy-proven NASH. Unfortunately safety and tolerability of glitazones limit their therapeutic potential. Ursodeoxycholic acid (UCDA) is not recommended for the treatment of NAFLD or NASH. Vitamin E, preferably at 800 IU daily in an alpha-tocopherol formulation should be considered as a first line therapy in patients with NASH but without diabetes mellitus. However there is controversy over its long-term safety.

CliniCal issues

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intractable gerd – what is next?Mohamed Hadzri Hasmoni

Department of Internal Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

It has been reported in various studies, up to a third of patients with GERD are either resistant or partial responders to proton pump inhibitor (PPI) therapy. Within the last decade, this cohort of patients has becoming more apparent in our daily clinical practice. Evidently, most of these patients suffer from functional heartburn and/or dyspepsia. Persistence of isolated or mixed acid, weakly acidic, bile or gas reflux, impaired oesophageal mucosal integrity, chemical or mechanical hypersensitivity to refluxates and psychological comorbidity are some potential mechanisms, postulated to be the underlying cause of failure of PPI treatment in these patients. Clarification of the actual nature and re-evaluation of the persistent symptoms is crucial in making the correct diagnosis. Despite being commonly used and endorsed, upper endoscopy has a limited diagnostic value. In contrast, reflux monitoring with pH or pH-impedance testing has been shown to be most beneficial for planning of subsequent management. Treatment options include oesophageal pain modulators, transient lower oesophageal sphincter relaxation (TLOSR) inhibitors, and anti-reflux surgery.

CliniCal issues

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iMaging of the liver lesionAhmad Helmy

Department of Radiology, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia

This lecture aims to explain radiological approach and imaging features of liver lesions. Imaging features of benign and malignant lesions will be covered on various radiological imaging modalities such as ultrasound, computed tomography scan, magnetic resonance imaging, angiography and nuclear medicine. Further division of these lesions into cystic or solid type in nature would be explained in order to clearly categorize the liver lesions. Common cystic benign lesions are cysts, abscess and hydatid disease. Common solid benign lesions are haemangioma, focal nodular hyperplasia, hepatic adenoma, focal fat and malignant lesions are hepatocellular carcinoma and hepatoblastoma. Metastases can present as cystic or solid lesion. Additional vascular lesions such as Budd-Chiari syndrome, portal venous hypertension and thrombosis would be briefly touched. It is hoped this lecture would impart and consolidate the knowledge of the participants in dealing with liver lesions.

CliniCal issues

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the role of ppis in functional dyspepsiaSanjiv Mahadeva

Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

The rationale for using PPIs in FD stems from both a clinical as well as a physiological perspective. One of the ideas that support the effectiveness of PPIs is the presence of many patients in whom non-erosive reflux disease (NERD) and FD overlap; anti-secretory therapy may have a role in such NERD/FD overlap patients. Besides this, pathological esophageal acid exposure has been reported in Western FD patients without symptoms of heartburn. To date, 7 randomized controlled trials of PPI versus placebo have been reported. In a recent meta-analysis combining the results of these 7 randomised trials, it was reported that there was a modest but statistically significant difference in symptom relief in patients receiving PPIs (40.3%) compared with those given placebo (32.7%), and the estimated number needed to treat was 14.6 patients (95% CI, 8.7 to 57.1). It must be noted that the only trial that showed negative results among the 7 trials in the meta-analysis was from Hong Kong. In addition, a recent randomized trial from Hong Kong that investigated the efficacy of a PPI on H. pylori-negative uninvestigated dyspeptic patients (epigastric pain and discomfort) also failed to show a superior effect of PPI over placebo. Characteristic differences between Asian and Western patients with FD may explain the lower benefit of PPIs in Asian patients. These data suggest that the efficacy of PPIs in patients with FD needs to be re-evaluated in the Asian population.

stomaCh

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salvage therapy for H pyloriRosemi Salleh

Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia

It is estimated about 6% of H pylori infection will not responded to the 1st and 2nd lines of treatment and need salvage therapy.Several factors may contribute to this problem which include patient, drugs resistance and compliance to therapy. Several regimens have been recommended to treat this subgroup of H pylori infection which include Quadriple Therapy, Levofloxacin based triple therapy and other regimens. The rate of eradication achieved are varies.

stomaCh

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loco-regional therapy in hcc – current status and future directions

Pierce Chow HPB Surgery, Singapore General Hospital, Singapore

Duke-NUS Graduate Medical School, Singapore National Medical Research Council, Singapore

Surgery provides the most consistent long-term survival in Hepatocellular Carcinoma and is the treatment of choice. Unfortunately the majority of HCC are diagnosed at a stage where they are inoperable. Locally advanced HCC (inoperable HCC, no distant metastases) have traditionally been treated with trans-arterial chemoembolization (TACE). Recent newer loco-regional therapies such as radio-frequency (RFA) and microwave ablation and Selective Internal Radiation Therapy (SIRT) have improved survival in this group of patients.

While smaller lesions can be effectively eradicated by RFA, Selective Internal Radiation Therapy (SIRT) is highly efficacious in larger lesions, when the lesions are multi-focal or when there is partial portal vein involvement. SIRT utilizes the short-range but high-energy beta-radiation of yttrium-90, a radioactive nuclide as brachytherapy and is particularly efficacious in HCC with vascular involvement. TACE however remains the most common form of therapy in locally advanced HCC because of its wide availability.

The emerging results of ongoing clinical trials on loco-regional therapy will define more precisely the evolving roles of these therapies. The experience of the Singapore General Hospital/National Cancer Center Singapore and the AHCC05 and 06 trials are discussed.

liver

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update on treatMent of chronic hepatitis Hamizah Razlan

Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Worldwide, chronic hepatitis C virus (HCV) infection is common with more than 180 million people are chronically infected with this virus. In Malaysia, approximately 1.5% of the population is infected with HCV. Chronic infection with HCV without treatment leads to a progressive hepatitis that can eventually lead to liver cirrhosis, liver failure or hepatocellular carcinoma (HCC).

The goal of treatment for HCV is to prevent these complications and to prolong survival. Sustained virological response (SVR), defined as undetectable levels of HCV RNA at least 24 weeks after completion of therapy is the primary endpoint of successful treatment. SVR is associated with clearance of the virus in more than 98% of cases.

The standard of care (SOC) therapy for patients with HCV has been the combination of pegylated interferon (PegIFN) with ribavirin (RBV). These drugs are administered for 48 weeks for genotype 1 infection and 24 weeks for genotype 2 or 3 infection. This combination treatment results in SVR rates of 40% – 50% in those with genotype 1 and 74-81% in patients with genotypes 2 and 3.

Recently, therapy for HCV was transformed by the use of direct antiviral agents (DAA). Studies had shown that adding a viral protease inhibitor, telaprevir (TVR) or boceprevir (BOC) to the PegIFN-RBV standard therapy in patients with HCV genotype 1 improved response rates with reduced duration of therapy. The use of on-treatment virological response or response guided therapy (RGT) in the current management of chronic hepatitis C had also allowed us to tailor treatment duration based on viral suppression in an individual patient.

liver

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low rectal cancer – can we spare the patient froM an abdoMinoperineal

resection?Akhtar Qureshi

Sunway Medical Centre, Petaling Jaya, Selangor, Malaysia

Colorectal cancer is today one of the most common causes of cancer deaths in patients in Malaysia. With increasing awareness more patients are being diagnosed with colorectal cancer. For the patients with low rectal cancer, commonly the primary option is an abdomino-perineal resection with a permanent colostomy. Whilst the abdomino-perineal resection can be a curative procedure, the idea of a permanent colostomy is difficult to accept for the average Malaysian patient for various reasons.

There are currently options available to avoid a permanent colostomy in a number of patients. These include the use of advanced surgical techniques with or without neoadjuvant chemoradiotherapy. Surgical options such as polypectomy and local excision, local transanal resection (full thickness resection), transanal endoscopic microsurgery (TEM) low anterior resection, and proctectomy with colo-anal anastomosis.

ColoreCtal

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starting biologics in asian ibd patientsNazri Mustaffa

Department of Medicine, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia

Although the incidence and prevalence of IBD is lower in Asia compared to Western countries, these have rapidly increased within the last two decades. There is also an increase in IBD rates amongst Asian immigrants to Western nations as compared to their native counterparts. In IBD patients who have had a poor response to conventional medications, rapidly adding biologics to their current therapeutic regime is highly desirable in order to reduce the risk of disease progression. Nevertheless, certain issues have to be considered before starting biologics in patients from the Asia-Pacific region. As tuberculosis is endemic in Asian countries, extra precautions have to be taken to ensure that patients are free from this before biologic therapy is initiated. Vaccinations are also important – patients need to have their vaccination history updated prior to starting biologics. Then there is also the cost factor; long-term biologic therapy is expensive and thus the duration that these medications are administered may differ when compared to Western practices. It is therefore important to keep these issues in mind when initiating biologic therapy in IBD patients of Asian origin.

ColoreCtal

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ManageMent of biliary stricturesRaman Muthukaruppan

Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

Bile duct stricture is an uncommon but challenging clinical entity that needs a coordinated multidisciplinary approach involving gastroenterologists, radiologists and surgeons. Bile duct strictures may be asymptomatic but, if ignored can lead to lethal complications, such as ascending cholangitis, liver abscess and secondary biliary cirrhosis. Most benign biliary strictures are iatrogenic, caused by operative injury mainly post-cholecystectomy. Others are being pancreatitis, TB and PSC. Malignant biliary strictures are caused by pancreatic cancer, ampullary cancer, gall bladder cancer, cholangiocarcinoma and hepatoma.

Important elements in the assessment and management of biliary strictures include:

1. Stricture characterisation : length, width, location and assessment of malignancy

(Done by assessment of history, laboratory studies and imaging results)

2. Endoscopic stricture access, with dilation and stent placement for unresectable malignant lesions and most benign lesions

3. Medical management for specific inflammatory lesions

4. Surgical management for resectable malignant lesions and selected benign lesions.

The cornerstone of managing biliary strictures is to determine nature of the stricture, whether it is benign or malignant and then direct therapy accordingly. History and laboratory investigations like CA 19.9 and serum IgG4 levels can help in the diagnosis and management. Suspected malignant strictures with an associated mass lesion can often be confirmed with EUS guided FNA. Benign strictures with an antecedent history of surgery or trauma can be managed without the risk or expense of sampling.

Management of benign biliary strictures should be aimed at achieving patency of the bile duct. Traditionally, surgery has been employed to treat these strictures, particularly if they are post-operative related. Now endoscopy has become the main stay in the treatment of these benign strictures.

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This is due to the fact that the morbidity and mortality rates associated with endoscopy are much lower than those of surgery. Furthermore most studies suggest that in majority of cases, endoscopy is as effective as surgery, particularly in short to medium term. The initial treatment options depend upon the location, severity and aetiology of the stricture as well as the patient’s overall health. On the other hand asymptomatic patients with biliary strictures secondary to pancreatitis will be best managed by a ‘wait-and-watch’ approach. Medical treatment’s main role is to stabilize a patient and manage any complications that develop secondary to bile duct strictures, particularly till a more definitive therapy can be achieved. This includes antibiotic therapy and other supportive treatment in those with cholangitis. Generally, patients who have benign strictures do well after completing endoscopic stenting or surgery, unlike patients with malignant biliary strictures.

Management of malignant strictures depend upon resectability. Resectable strictures generally do not warrant preoperative stenting. However stenting is indicated in those patients with cholangitis and in those with delayed surgery beyond 1-2 weeks due to neoadjuvant therapy etc. Plastic stents are most cost effective for short term use. Malignant strictures which are surgically unresectable warrant the least costly drainage that will provide palliation without need for reintervention. Metal stents offer longer patency than plastic stents, hence indicated for palliation in patients with advanced cancer. Both covered and uncovered (bare) metal stents are being widely used now.

Indeterminate strictures will require plastic stents in general to provide biliary drainage until decision regarding surgery is made. Metal stents are labelled for malignant strictures only, but of late, there are studies to show the usefulness of fully-covered SEMS in benign and indeterminate lesions.

Date post:	12-Mar-2018
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