Interpreting an Irritable
Bowel Syndrome Diagnosis
Yap Chin Kong Gastroenterology & LiverClinic
Dr Yap Chin Kong
Consultan...
Typical IBS sufferer
Irritable bowel syndrome
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Healt...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Other symptoms
Gas and ...
Pain, diarrhea,
bloating etc
Hmmm...
IBS
Address patient’s symptoms
Address patient’s concerns
I’m concerned
of cancer -
my colleague
had it
A colonoscopy
will rule that out
Is it irritable bowel syndrome ?
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreat...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Diagnostic approach to ...
Investigations - tools
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
...
White blood cell
Red blood cell
Features of colon inflammation
Simple stool test
Warning signs: may not be IBS
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic ...
Doctor’s role: a fine balance
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic ...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
I Functional
Motility d...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
II Organic
Acid relate...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
IBS and NETs
 IBS does...
Features of carcinoid (NET)
Ito T, J Gastroenterol 2010
No symptoms 70%
Carcinoid syndrome 3%
Carcinoid syndrome
Flushing
...
Ito T, J Gastroenterol 2010
Symptoms in carcinoid patients
Diarrhea 4%
Constipation 10%
Abdomen pain 27%
Flushing 1%
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Esophagus
Stomach
Duode...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Esophagus
Stomach
Duode...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Esophagus
Stomach
Duode...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Esophagus
Stomach
Duode...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Esophagus
Stomach
Duode...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Esophagus
Stomach
Duode...
Video
capsule
“endoscopy”
PET scan
Endoscopic ultrasound scan revealed two
1 cm size tumors ? NET
Challenges in IBS
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
1 Com...
Given a case study, willingness to diagnose
IBS on history & physical examination alone
Am J Gastroenterol 2010;105:848-
Y...
Colon cancer (Singapore)
Colon cancer (Singapore)
1:20 life time risk
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Non-functioning NET doe...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Functioning NET produce...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Production of hormone b...
USA
GI + pancreatic NET is 2.85 per 100,000
Total NET is 5 per 100,000
Yap Chin Kong Gastroenterology & Liver Clinic
For D...
Colon cancer (Singapore)
Carcinoid, NET (USA)
5 per 100,000
(male+female)
38 per
100,000
(male+female)
Carcinoid, NET (Sin...
Singapore Cancer Statistics 1993-2002
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pan...
Singapore Cancer Statistics 1993-2002
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pan...
Why is there a difference ?
• Singapore 300-400 cases NET-cancer over 10
years.
• If we applied USA figures, we expect abo...
P-NET 0.32/100,000 1.01/100,000
GI-NET 2.53/100,000 2.10/100,000
Total 2.85/100,000 3.11/100,000
Yao JC, J Clin Onco 2008
...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
A test is available for...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
The Perfect World - A P...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
The Real World
True Pos...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
The Real World
True Pos...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Test A for disease X
Te...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Test B for disease X
Te...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
What to do with a posit...
Sensitivity 85% Specificity 85%
1,000 persons True + (85%) False + (15%)
0 disease 0 150
10 disease (1%) 8.5 150
100 disea...
Sensitivity 98% Specificity 98%
1,000 persons True + (98%) False (2%)
0 disease 0 20
10 disease (1%) 9.8 20
100 disease
(1...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Principles of testing
1...
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pancreatic Health
Principles of testing
1...
Rectum carcinoid confirmed
CgA normal (false negative test)
Carcinoid (neuroendocrine) tumor
• NET is out there
• Not every type of pre-cancer or cancer can be detected
early with sc...
• Promote and ride on colon cancer screening which is on-
going. Opportunistic screening for gastric, rectum and
ileum NET...
Singapore Cancer Statistics 1993-2002
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pan...
Singapore Cancer Statistics 1993-2002
Yap Chin Kong Gastroenterology & Liver Clinic
For Digestive, Colorectal, Liver & Pan...
Risks of
medical tests
Managing your risks
We see examples of risk every day
Risk and benefit
go together
Managing your risks
• Risk is part of medical tests and treatment
• Weigh “risks” vs “benefits”: test vs non-test
• Weigh ...
Risk of colonoscopy
Sedation risk
•For maximum safety, comfort, perform in a center
with monitoring facilities
•Get a doct...
Risk of colonoscopy
Procedure risk:
•Perforation, bleeding. Get a doctor with
experience, good track record: personal zero...
CT colonography
Arch Intern Med 2009;169(22):2078-2086
Radiation Dose Associated with
Common Computed Tomography
Examinations and the Asso...
Age 20 yr Age 40 yr Age 60 yr
F M F M F M
CT abdomen 250 330 460 498 700 660
CT coronary 150 390 270 595 420 790
CT brain ...
Doctors try our best
It’s not nice to be sick ....
But there are risks & benefits
In the diagnostic and
therapeutic journey
First do no harm
Given an existing problem, it may be
better not to do something, or even do
nothing, than to risk doing m...
Do I need a CgA test?
No!
High false positive results
I attended a talk on
carcinoid.
I am worried. I have no
symptoms
Do I need a CgA test?
No!
Unless symptoms are atypical
on periodic review
I have typical
IBS
symptoms
Do I need a CgA test?
Maybe!
Diagnose the cause of
diarrhea: blood, stool tests,
colonoscopy, biopsies,
± CT scan
If suspe...
Do I need a CgA test?
I have a family
member with
carcinoid
Yes!
Gastroscopy, colonoscopy
Gallium PET scan baseline?
How f...
Do I need a CgA test?
Dr Yap performed a
colonoscopy. He found and
removed an incidental
rectum carcinoid
Yes!
Up to 25% h...
Diarrhea & pain can be a challenging
diagnosis
NETs in Singapore:
Unanswered questions
More research and statistics needed...
IBS NETColon cancer
Other causes
IBS symptoms
He who has health has
hope,
He who has hope has
everything
Yap Chin Kong Gastroenterology & LiverClinic
Wishing everyone good
health
Thank you!
Yap Chin Kong Gastroenterology & LiverClinic
www.gastroliver.com.sg
Irritable bowel syndrome - interpreting a diagnosis
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Irritable bowel syndrome - interpreting a diagnosis

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Public Lecture delivered on 20 November 2010 at Health Promotion Board Auditorium, SIngapore. Organized by CNETS.

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  • Relative risk is 5 fold higher than 30 years ago Absolute risk is rare 1:100,000 Analogy is if you have a 1 in million chance of winning the lottery, if you increase your chances 10 x, you still have an absolute risk of 10 in a million chance, which is still very small.
  • Irritable bowel syndrome - interpreting a diagnosis

    1. 1. Interpreting an Irritable Bowel Syndrome Diagnosis Yap Chin Kong Gastroenterology & LiverClinic Dr Yap Chin Kong Consultant Gastroenterologist Hepatologist & Clinic Director MBBS, MMed, MRCP, FRCP @ Mount Elizabeth Medical Centre, Singapore
    2. 2. Typical IBS sufferer
    3. 3. Irritable bowel syndrome Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Diagnostic criteria (Manning/Rome) 1 Abdomen pain relieved by defecation 2 Looser stools at onset of pain 3 Frequent stools at onset of pain 4 Abdomen distension 5 Passage of mucus in stools 6 Sensation of incomplete defecation
    4. 4. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Other symptoms Gas and bloating Visible abdomen swelling Abdomen pain or discomfort Heartburn Back and muscle ache (fibromyalgia) Irritable bowel syndrome
    5. 5. Pain, diarrhea, bloating etc Hmmm... IBS Address patient’s symptoms
    6. 6. Address patient’s concerns I’m concerned of cancer - my colleague had it A colonoscopy will rule that out
    7. 7. Is it irritable bowel syndrome ? Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Addressing patient’s concerns 1 Worried about serious disease 2 Wants to rule out colon cancer, inflammatory bowel disease, celiac disease 3 Wants relief of symptoms: pain, diarrhea etc 4 Up to 10% of population have IBS
    8. 8. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Diagnostic approach to abdomen symptoms Addressing patient’s concerns History is very important Examination: BMI (weight, height) Pale, jaundice Mass in abdomen Enlarged liver Tenderness Lumps (lymph nodes) Rectum examination
    9. 9. Investigations - tools Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Addressing patient’s concerns 1 Blood, stool tests: anemia, inflammation, celiac disease in Caucasian 2 Colonoscopy to exclude colon cancer, inflammatory bowel disease, others 3 Ultrasound scan: liver, pancreas, gallbladder, ovaries 4 Reserve list: Gastroscopy, video capsule, CT scans
    10. 10. White blood cell Red blood cell Features of colon inflammation Simple stool test
    11. 11. Warning signs: may not be IBS Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health 1 Moderately severe pain alone 2 No relationship with bowel movement 3 Severe diarrhea or diarrhea alone 4 Passage of blood 5 Weight loss 6 Fever 7 Anemia
    12. 12. Doctor’s role: a fine balance Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Not doing enough to exclude serious disease Doing too many tests Some may have risks Cost Balance patient’s concerns with realities
    13. 13. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health I Functional Motility disorder with visceral sensitivity No structural abnormality Irritable bowel syndrome IBS- Constipation IBS- Diarrhea IBS- Constipation/Diarrhea Some causes of abdomen pain
    14. 14. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health II Organic Acid related: GERD, ulcer Cancer ± diarrhea Inflammatory bowel disease (Crohn’s, ulcerative colitis) ± diarrhea Eosinophilic enteritis ± diarrhea Ischemic colitis ± diarrhea Diverticulitis ± diarrhea Infections (ameba, tuberculosis) ± diarrhea Celiac sprue ± diarrhea Tropical sprue ± diarrhea Stones in gallbladder or bile duct ± diarrhea Carcinoid (neuroendocrine tumor) with liver metastases ± diarrhea Carcinoid (neuroendocrine tumor) lung ± diarrhea (no pain) Some causes of abdomen pain
    15. 15. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health IBS and NETs  IBS does not transform or increase the risk of NET  Patients with “IBS” and NET tumor may be due to (i) wrong IBS diagnosis (ii) correct IBS diagnosis + development of a new NET sequentially (iii) chance association simultaneously “guilt by association” vs “cause and effect”
    16. 16. Features of carcinoid (NET) Ito T, J Gastroenterol 2010 No symptoms 70% Carcinoid syndrome 3% Carcinoid syndrome Flushing Severe diarrhea Crampy pain Nausea, vomiting Wheezing
    17. 17. Ito T, J Gastroenterol 2010 Symptoms in carcinoid patients Diarrhea 4% Constipation 10% Abdomen pain 27% Flushing 1%
    18. 18. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Esophagus Stomach Duodenum Small intestine Large intestine Gallbladder Bile duct Pancreas Liver Long digestive tract
    19. 19. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Esophagus Stomach Duodenum Small intestine Large intestine Gallbladder Bile duct Pancreas Liver Long digestive tract We have the technology to examine the entire digestive system from mouth to anus
    20. 20. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Esophagus Stomach Duodenum Small intestine Large intestine Gallbladder Bile duct Pancreas Liver Gastroscopy
    21. 21. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Esophagus Stomach Duodenum Small intestine Large intestine Gallbladder Bile duct Pancreas Liver Colonoscopy
    22. 22. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Esophagus Stomach Duodenum Small intestine Large intestine Gallbladder Bile duct Pancreas Liver Video capsule “endoscopy”
    23. 23. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Esophagus Stomach Duodenum Small intestine Large intestine Gallbladder Bile duct Pancreas Liver Scans, endoscopic ultrasound
    24. 24. Video capsule “endoscopy”
    25. 25. PET scan
    26. 26. Endoscopic ultrasound scan revealed two 1 cm size tumors ? NET
    27. 27. Challenges in IBS Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health 1 Common condition 10% population affected 2 Not always an easy diagnosis to make with complete confidence 3 Because IBS is common, we get it right most of the time 4 Challenge is to identify the “IBS-like” case that is not really IBS 5 One consultation is not enough 6 Follow up is important to look for evolution and re-evaluate 7 “Difficult IBS” gets investigated the most 8 Correctly diagnosed “IBS” does not prevent the occurrence of another disease later on
    28. 28. Given a case study, willingness to diagnose IBS on history & physical examination alone Am J Gastroenterol 2010;105:848- Yes No Unsure IBS experts 70% 7% 23% Community gastroenterologists 52% 3% 45% General internal medicine physicians 34% 7% 59% Nurse practitioners 41% 9% 50%
    29. 29. Colon cancer (Singapore)
    30. 30. Colon cancer (Singapore) 1:20 life time risk
    31. 31. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Non-functioning NET does not produce hormone Asymptomatic carcinoid When NET grows bigger, can cause pain, bleeding, obstruction How does carcinoid(NET) cause diarrhea ?
    32. 32. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Functioning NET produces hormone (serotonin) Hormone in intestine goes to liver Hormone is destroyed by liver No hormone in blood, therefore no diarrhea Asymptomatic carcinoid How does carcinoid(NET) cause diarrhea ?
    33. 33. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Production of hormone by tumor metastases in the liver Hormone from the liver is released into the blood Hormone in blood causes diarrhea Gastrointestinal carcinoids (NETs) present late by the time diarrhea occurs OR NET in lung produces hormone that is released in the blood therefore causes diarrhea How does carcinoid(NET) cause diarrhea ?
    34. 34. USA GI + pancreatic NET is 2.85 per 100,000 Total NET is 5 per 100,000 Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Carcinoid
    35. 35. Colon cancer (Singapore) Carcinoid, NET (USA) 5 per 100,000 (male+female) 38 per 100,000 (male+female) Carcinoid, NET (Singapore)??? Incidence Statistics 1993-2002
    36. 36. Singapore Cancer Statistics 1993-2002 Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Sitenumber cases Adeno-cancer NET-cancer Rectum 3,893 115 Lung 3,416 80 Colon 5,676 70 Stomach 3,188 26 Small intestine 95 24 Pancreas 510 8 Total cases 16,778 323
    37. 37. Singapore Cancer Statistics 1993-2002 Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Sitenumber cases Adeno-cancer NET-cancer Rectum 3,893 115 Lung 3,416 80 Colon 5,676 70 Stomach 3,188 26 Small intestine 95 24 Pancreas 510 8 Total cases 16,778 323 300,000 cases IBS (10% of 3 million)
    38. 38. Why is there a difference ? • Singapore 300-400 cases NET-cancer over 10 years. • If we applied USA figures, we expect about 2,000 cases NETs over 10 years • Possible reasons (i) Real differences between East and West (ii) Under diagnosed (iii) Under reported: NET-cancer is notifiable, but NET is not. More study needed Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
    39. 39. P-NET 0.32/100,000 1.01/100,000 GI-NET 2.53/100,000 2.10/100,000 Total 2.85/100,000 3.11/100,000 Yao JC, J Clin Onco 2008 Ito T, J Gastroenterol 2010 Incidence rates: West vs East
    40. 40. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health A test is available for NET: Chromogranin A
    41. 41. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health The Perfect World - A Perfect Test Sensitivity 100% Specificity 100% True Positive = disease present True Negative = disease absent
    42. 42. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health The Real World True Positive = disease present True Negative = disease absent False Positive = false alarm False Negative = disease missed
    43. 43. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health The Real World True Positive = disease present True Negative = disease absent False Positive = false alarm False Negative = disease missed
    44. 44. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Test A for disease X Test 1,000 people. Assume disease X is present in 1% = 10 people Sensitivity = 85% Specificity = 85%, false positive = 15% 85/100 x 10 = 8.5 have disease X (true positive) Number of false positive tests is 15/100 x 1,000 = 150 persons Total = 159 positive tests
    45. 45. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Test B for disease X Test 1,000 people. Assume disease X is present in 1% = 10 people Sensitivity =98% Specificity = 98%, false positive = 2% 98/100 x 10 = 9.8 have disease X (true positive) Number of false positive tests is 2/100 x 1,000 = 20 persons Total = 30 positive tests
    46. 46. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health What to do with a positive test? Further tests Scans, Bronchoscopy, Gastroscopy, Colonoscopy, Biopsy True Positive test Disease X False Positive test Normal people Test A = positive tests 1,000 tested Disease X = 10 Normal = 990
    47. 47. Sensitivity 85% Specificity 85% 1,000 persons True + (85%) False + (15%) 0 disease 0 150 10 disease (1%) 8.5 150 100 disease (10%) 85 150 500 disease (50%) 425 150 Test A for disease X
    48. 48. Sensitivity 98% Specificity 98% 1,000 persons True + (98%) False (2%) 0 disease 0 20 10 disease (1%) 9.8 20 100 disease (10%) 98 20 500 disease (50%) 490 20 Test B for disease X
    49. 49. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Principles of testing 1 High occurrence of disease - high pick up rate 2 Low occurrence of disease - low pick up rate 3 Low occurrence disease, most positive tests are false positive 4 High occurrence disease, most positive tests are true positive 4 More people tested - more disease found 5 More people tested - more false positive tests found 6 Positive test needs further tests to differentiate true disease from a false alarm
    50. 50. Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Principles of testing 1 Choosing a high risk group (with high occurrence of disease) will increase the yield and reduce false positive 2 High risk group for NET tumor is a family history of NET tumor 3 “IBS” is not recognized as a high risk group for screening
    51. 51. Rectum carcinoid confirmed CgA normal (false negative test)
    52. 52. Carcinoid (neuroendocrine) tumor • NET is out there • Not every type of pre-cancer or cancer can be detected early with screening • There are benefits and harm from screening a balance has to be achieved • Testing in patient with symptoms = diagnostic testing • Testing in healthy person with no symptoms = screening Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
    53. 53. • Promote and ride on colon cancer screening which is on- going. Opportunistic screening for gastric, rectum and ileum NETs during gastroscopy and colonoscopy for other reasons • Small intestine NETs are nearly impossible to diagnose early • Consider the possibility of the condition in those with • prominent diarrhea (mimic IBS) • facial flush • wheezing (mimic asthma) • Unfortunately these symptoms indicate late metastatic disease for NET in the gut and are rare • May be early disease for NET in the lung What can we do now ? Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
    54. 54. Singapore Cancer Statistics 1993-2002 Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Sitenumber cases Adeno-cancer NET-cancer Rectum 3,893 115 (36%) Lung 3,416 80 Colon 5,676 70 (22%) Stomach 3,188 26 (7%) Small intestine 95 24 Pancreas 510 8 Total cases 16,778 323 GI-NET cancer Rectum + colon + stomach account for 65% of all NET cancer
    55. 55. Singapore Cancer Statistics 1993-2002 Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health Sitenumber cases Adeno-cancer NET-cancer Rectum 3,893 115 (36%) Lung 3,416 80 Colon 5,676 70 (22%) Stomach 3,188 26 (7%) Small intestine 95 24 Pancreas 510 8 Total cases 16,778 323 Arising from the large numbers of gastroscopies and colonoscopies performed daily, there is opportunistic screening
    56. 56. Risks of medical tests
    57. 57. Managing your risks We see examples of risk every day
    58. 58. Risk and benefit go together
    59. 59. Managing your risks • Risk is part of medical tests and treatment • Weigh “risks” vs “benefits”: test vs non-test • Weigh “risks” vs “benefits”: treatment vs non- treatment Choose your doctor Experience with carcinoid Don’t hurry colonoscopy: tumors are small Track record
    60. 60. Risk of colonoscopy Sedation risk •For maximum safety, comfort, perform in a center with monitoring facilities •Get a doctor who is experienced, good track record: personal no sedation mishaps in 20 years, >10,000 procedures •Colonoscopy is possible without sedation •Awake colonoscopy - mild discomfort - case by case basis Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
    61. 61. Risk of colonoscopy Procedure risk: •Perforation, bleeding. Get a doctor with experience, good track record: personal zero perforation rate in 20 years •Good colonoscopy technique Yap Chin Kong Gastroenterology & Liver Clinic For Digestive, Colorectal, Liver & Pancreatic Health
    62. 62. CT colonography
    63. 63. Arch Intern Med 2009;169(22):2078-2086 Radiation Dose Associated with Common Computed Tomography Examinations and the Associated Lifetime Attributable Risk of Cancer
    64. 64. Age 20 yr Age 40 yr Age 60 yr F M F M F M CT abdomen 250 330 460 498 700 660 CT coronary 150 390 270 595 420 790 CT brain 4,630 7,350 8,100 11,080 12,250 14,680 CT colon Not analysed Number of CT scans to give rise to 1 cancer Arch Intern Med 2009;169(22):2078-2086
    65. 65. Doctors try our best It’s not nice to be sick .... But there are risks & benefits In the diagnostic and therapeutic journey
    66. 66. First do no harm Given an existing problem, it may be better not to do something, or even do nothing, than to risk doing more harm than good Human acts with good intentions may have unwarranted consequences
    67. 67. Do I need a CgA test? No! High false positive results I attended a talk on carcinoid. I am worried. I have no symptoms
    68. 68. Do I need a CgA test? No! Unless symptoms are atypical on periodic review I have typical IBS symptoms
    69. 69. Do I need a CgA test? Maybe! Diagnose the cause of diarrhea: blood, stool tests, colonoscopy, biopsies, ± CT scan If suspect NET do CgA test I have persistent diarrhea for one month and lost weight
    70. 70. Do I need a CgA test? I have a family member with carcinoid Yes! Gastroscopy, colonoscopy Gallium PET scan baseline? How frequent? Annually? Q: CgA is negative, does it mean I am safe ?
    71. 71. Do I need a CgA test? Dr Yap performed a colonoscopy. He found and removed an incidental rectum carcinoid Yes! Up to 25% have another tumor Gastroscopy, colonoscopy Gallium PET scan baseline? How frequent? Annually? Q: CgA is negative, does it mean I am cured ?
    72. 72. Diarrhea & pain can be a challenging diagnosis NETs in Singapore: Unanswered questions More research and statistics needed Be mindful of the possibility but not over-react Maintain a balanced approach and perspective Maintain patient-centric focus
    73. 73. IBS NETColon cancer Other causes IBS symptoms
    74. 74. He who has health has hope, He who has hope has everything Yap Chin Kong Gastroenterology & LiverClinic
    75. 75. Wishing everyone good health Thank you! Yap Chin Kong Gastroenterology & LiverClinic www.gastroliver.com.sg

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