New Book: Gastroenterology and Hepatology A Manual, Isidor Segal


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The rise of international travel has given previously region-specific diseases a global presence. The book is aimed at students, interns, fellows and health care providers.It contains chapters devoted to clinical examination and an outline of how to approach common problems encountered at the bedside. The format and style of the book allows common clinical problems to be identified and recognised within the framework of a global perspective.

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New Book: Gastroenterology and Hepatology A Manual, Isidor Segal

  1. 1. Gastroenterologyand Hepatology CK ICK LI FManual QUA Clinician’s Guideto a Global Phenomenon ly on s ge paIsidor Segal eC.S. Pitchumoni pl amJoseph Sung S
  2. 2. Gastroenterology and Hepatology Manual ly on s ge pa e pl am S
  3. 3. ii CONTENTS Dedication Professor Segal To my wife Arlene for her unstinting devotion and to my dear children Rosh, Perry, Hadass and their families for their continuing understanding and support. Professor Pitchumoni To my wife Prema Pitchumoni and to all my students Professor Sung To members of the GI team at Prince of Wales Hospital ly on s ge pa e pl am S
  4. 4. Gastroenterology and Hepatology Manual A Clinician’s Guide to a Global Phenomenon Isidor Segal C.S. Pitchumoni Joseph Sung ly on s ge pa e pl am S
  5. 5. NoticeMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge,changes in treatment and drug therapy are required. The editors and the publisher of this work havechecked with sources believed to be reliable in their efforts to provide information that is completeand generally in accord with the standards accepted at the time of publication. However, in view ofthe possibility of human error or changes in medical sciences, neither the editors, nor the publisher,nor any other party who has been involved in the preparation or publication of this work warrants thatthe information contained herein is in every respect accurate or complete. Readers are encouraged toconfirm the information contained herein with other sources. For example, and in particular, readersare advised to check the product information sheet included in the package of each drug they planto administer to be certain that the information contained in this book is accurate and that changeshave not been made in the recommended dose or in the contraindications for administration. Thisrecommendation is of particular importance in connection with new or infrequently used drugs.First published 2011Text © 2011 McGraw-Hill Australia Pty LtdIllustrations and design © 2011 McGraw-Hill Australia Pty LtdAdditional owners of copyright are acknowledged in on-page credits.Every effort has been made to trace and acknowledge copyrighted material. The authors and publisherstender their apologies should any infringement have occurred.Reproduction and communication for educational purposesThe Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of thiswork, whichever is the greater, to be reproduced and/or communicated by any educational institution forits educational purposes provided that the institution (or the body that administers it) has sent a StatutoryEducational notice to Copyright Agency Limited (CAL) and been granted a licence. For details of statutoryeducational and other copyright licences contact: Copyright Agency Limited, Level 15, 233 CastlereaghStreet, Sydney NSW 2000. Telephone: (02) 9394 7600. Website: and communication for other purposesApart from any fair dealing for the purposes of study, research, criticism or review, as permitted underthe Act, no part of this publication may be reproduced, distributed or transmitted in any form or byany means, or stored in a database or retrieval system, without the written permission of McGraw-HillAustralia including, but not limited to, any network or other electronic storage.Enquiries should be made to the publisher via or marked for the attention ofthe permissions editor at the address below.National Library of Australia Cataloguing-in-Publication DataAuthor: Segal, Isidor.Title: Gastroenterology and hepatology manual : a clinician’s guide to a global phenomenon / Isidor Segal, C.S. Pitchumoni, Joseph Sung. lyISBN: 9780070285576 (pbk.)Notes: Includes index. onSubjects: Gastroenterology--Handbooks, manuals, etc.Other Authors/Contributors: Pitchumoni, C.S., Sung, Joseph.Dewey Number: 616.33 sPublished in Australia by geMcGraw-Hill Australia Pty LtdLevel 2, 82 Waterloo Road, North Ryde NSW 2113 paAcquisitions editor: Elizabeth WaltonAssociate editor: Fiona RichardsonArt direction and cover design: Astred Hicks eInternal design: Peta NugentSenior production editor: Yani Silvana plPermissions editor: Haidi BernhardtCopy editor: Ross Blackwood amProofreader: Anne SavageIndexer: Russell BrooksTypeset in Zapf Humanist 601 BT, 8/10.5 by Mukesh Technologies, India SPrinted in China on 80gsm matt art by iBook Printing Ltd
  6. 6. ForewordRapid globalisation is affecting all aspects of life, and the practice of medicineis no exception. Gastroenterology and Hepatology: a Clinician’s Guide to aGlobal Phenomenon is a thoughtful attempt to address the issues related tothe teaching and clinical practice of gastroenterology and hepatology in thecurrent climate. The book is creatively organised and the chapters have beenwritten by a team of international experts in the field. Gastroenterology and Hepatology contains carefully selected topicsthat are of particular importance to the practice of gastroenterology andhepatology throughout the world. Chapter 1, for example, provides ascholarly, coherent discussion of the underlying factors that are propellingthe development of diseases that are similar worldwide, and of the evolutionfrom regional to global medicine, particularly in the field of gastroenterologyand hepatology. The popularity of international travel has resulted in travellers beingexposed to new gastrointestinal and liver disorders that are not present intheir homelands. The chapters devoted to international travel medicineprovide useful information on the diagnosis and management ofgastrointestinal and liver disorders both for travellers from different parts ofthe world to a common destination and for travellers from one region tovaried regions. The editors have cleverly divided clinical gastrointestinal and liverdisorders into groups, such as diseases that are common in West but seemto spreading to the East, diseases that are common in emerging countriesand spreading globally, and diseases that represent the melting pot. Other lychapters discuss diseases—including gastrointestinal and liver cancers—that onhave different epidemiology, pathophysiology and clinical behaviour indifferent parts of the world. Chapters discussing gastrointestinal and hepatic disorders of global s geimportance include: one on the differences in the diagnostic tools that areused by practitioners for diagnosis and management of the same disorders in padifferent parts of the globe; chapters dealing with important liver disordersof international interest because of the diversity of their epidemiology andclinical presentation; and chapters on biliary and pancreatic disorders that ediscuss global diversity in epidemiology, aetiology, clinical manifestations and plmanagement of these disorders. am Finally, the book includes a chapter on Chinese traditional medicine andanother on Indian traditional medicine, both focused on gastrointestinal and S
  7. 7. vi FOREWORDliver diseases. Throughout the world, the vast majority of these diseases arebeing treated with alternatives to conventional medicine practised in theWest. Moreover, many of the practitioners of alternative forms of medicineare now also formally trained in Western medicine. This understanding ofdifferent types of therapies will no doubt be beneficial for patients. This unique compilation, written by talented, scholarly contributorswith expertise in international medicine, is a pioneering work in globalgastroenterology and hepatology. Students and practitioners who care forpatients in the global environment will find this book very useful. Raj K. Goyal, MD Mallinckrodt Professor of Medicine Harvard Medical School VA Boston Health Care Boston, Massachusetts 02132 ly on s ge pa e pl am S
  8. 8. ContentsForeword vAbout the editors xAbout the contributors xiAcknowledgments xviSection 1: An overview 1Chapter 01 • Introduction 2Chapter 02 • A global phenomenon: medicine without 4 frontiersSection 2: Gastrointestinal diseases 13Part A: Clinical assessments 14Chapter 03 • Acute and chronic abdominal pain 14Part B: Western diseases spreading their wings 26Chapter 04 • Gastro-oesophageal reflux disease (GERD) 26Chapter 05 • Irritable bowel syndrome 39Chapter 06 • Changing patterns of inflammatory bowel disease 48 in a global context (ulcerative colitis)Chapter 07 • Changing patterns of inflammatory bowel disease 66 ly in a global context (Crohn’s disease) onChapter 08 • Constipation 77Chapter 09 • Colorectal cancer 92 sPart C: Diseases of emerging countries making inroads globally 100 geChapter 10 • Gastrointestinal tuberculosis versus Crohn’s 100 pa diseaseChapter 11 • Traveller’s diarrhoea 114 eChapter 12 • Cholera 126 plChapter 13 • Malaria 139 amChapter 14 • Leptospirosis 156 S
  9. 9. viii CONTENTS Chapter 15 • Listeriosis 163 Chapter 16 • Amoebiasis 171 Chapter 17 • Schistosomiasis: global impact 181 Part D: Diseases in the melting pot 191 Chapter 18 • Giardiasis, cryptosporidiosis and cyclosporiasis 191 Chapter 19 • Gastrointestinal disorders in HIV infection 197 and other sexually transmitted infections Par t E: Cancers of the gastrointestinal tract 207 Chapter 20 • Cancer of the oesophagus: intercontinental 207 variations Chapter 21 • Global trends in gastric cancer: association with 217 Helicobacter pylori and other factors Chapter 22 • Clinical aspects of gastric cancer 223 Part F: Preventative gastroenterology 227 Chapter 23 • Preventative gastroenterology 227 Part G: Nutrition 242 Chapter 24 • Nutritional evaluation: a paradigm shift in the 242 twenty-first century Chapter 25 • Impact on children of global nutritional 257 breakdown Part H: Gastrointestinal tools 270 ly Chapter 26 • Gastrointestinal bleeding 270 on Chapter 27 • Gastrointestinal endoscopy: an overview 280 Chapter 28 • Alimentary tract imaging 292 s ge Section 3: Pancreatic diseases 303 Chapter 29 • Acute pancreatitis 304 pa Chapter 30 • Chronic pancreatitis 316 e Chapter 31 • Pancreatic cancer 328 pl Chapter 32 • Imaging of the pancreas 335 am S
  10. 10. CONTENTS ixSection 4: Hepatology 347Part A: Diseases evoking a global impact 348Chapter 33 • Cirrhosis and complications 348Chapter 34 • Acute liver failure 369Chapter 35 • Acute hepatitis 381Chapter 36 • Hepatitis B infection 394Chapter 37 • Hepatitis C infection 409Chapter 38 • Non-alcoholic fatty liver disease 422Chapter 39 • Alcoholic liver disease 437Chapter 40 • Hepatocellular carcinoma 444Chapter 41 • Hepatic imaging 453Part B: Biliary diseases 465Chapter 42 • Gallstones and their sequelae 465Chapter 43 • Neoplasms of the gall bladder and biliary tracts 475Chapter 44 • Imaging of biliary tracts 489Section 5: Traditional cultural medicine 499Chapter 45 • Traditional Chinese medicine 500Chapter 46 • Traditional Indian medicine 514Index 526 ly on s ge pa e pl am S
  11. 11. About the editorsIsidor Segal FRACP, FRCP (UK), AGAF, Master WorldGastroenterology Organisation (WGO)Professor Segal established the African Institute of Digestive Diseases in1999. The model of this institute has been used by the WGO to establish13 training centres in countries such as Morocco, Pakistan, Bangkok, Egypt,Chile, Bolivia and Argentina. Professor Segal has held many positions in the WGO, including: memberof the Education and Training Committee and Vice Chairman African andMiddle East Zone. He has published more than 200 papers and has recentlyco-edited two books and is a visiting lecturer at universities around the world.He is currently working in the Gastroenterology Division at Prince of WalesHospital, Sydney.C.S. Pitchumoni MD, MACP, MACG, AGAF, MPHProfessor Pitchumoni is the Adjunct Professor of Medicine at New YorkMedical College, Clinical Professor of Medicine at both Robert WoodJohnson School of Medicine at New Brunswick, New Jersey, and atDrexel University in Philadelphia, USA. Currently he is also Chief ofGastroenterology, Hepatology and Clinical Nutrition at Saint Peter’sUniversity Hospital in New Brunswick. Professor Pitchumoni has more than 40 years of teaching and researchexperience as a clinical gastroenterologist.Joseph Sung MD, PhD lyProfessor Sung is the President of the Chinese University of Hong Kong on(CUHK) and Mok Hing Yiu Professor of Medicine. Before this appointment,he was Director of the Institute of Digestive Disease, Chairman of the sDepartment of Medicine and Therapeutics, and Associate Dean of Medicine geat CUHK. He is a gastroenterologist with special interest in gastrointestinalbleeding, digestive cancer and hepatitis infection. He has published more pathan 650 full papers in scientific journals and edited or co-edited sevenbooks. e pl am S
  12. 12. About the contributorsM. Abdullah, IndonesiaDivision of Gastroenterology, Department of Internal Medicine, Faculty ofMedicine, University of Indonesia, Jakarta.R.M. Agrawal, USAAssociate Professor of Medicine, Drexel University College of Medicine,Philadelphia.Associate Clinical Chief, Research and Education, Division ofGastroenterology, Hepatology and Nutrition, Department of Medicine,Allegheny General Hospital, Pittsburgh.D.V. Alcid, USAProfessor of Medicine and Pathology, University of Medicine and Dentistry,Robert Wood Johnson Medical School, New Brunswick, New Jersey.Director, Microbiology Laboratory, St. Peter’s University Hospital,New Brunswick, New Jersey.D. Amarapurkar, IndiaBombay Hospital and Medical Research Centre; Mumbai and JagjivanramWestern Railway Hospital, Mumbai.T.L. Ang, SingaporeDepartment of Gastroenterology, Changi General Hospital.R. Banerjee, IndiaConsultant Gastroenterologist, Asian Institute of Gastroenterology, lyHyderabad, Andhra Pradesh. onZ. Bian, Hong Kong, ChinaSchool of Chinese Medicine, Hong Kong Baptist University. sM. Bilal, USA geUniversity of Tennessee Health Science Center, Memphis. paP. Chang, AustraliaGastroenterology Division, Prince of Wales Hospital, Sydney. e plJ. Chaganti, AustraliaSenior Lecturer in Radiology, University of New South Wales, Sydney. amSenior Consultant, Radiology, St Vincent’s Hospital, Sydney. S
  13. 13. XII ABOUT THE CONTRIBUTORSG.M. Dusheiko, EnglandProfessor of Medicine, Centre for Hepatology, Royal Free Hospital andUniversity College London Medical School.S.S. Fedail, SudanConsultant Physician and Gastroenterologist, Chairman, Fedail Hospital,Khartown.K.M. Fock, SingaporeDepartment of Gastroenterology, Changi General Hospital.A.Y. Garcia, CubaDepartment of Gastroenterology, National Institute of Gastroenterology,Havana.K.L. Goh, MalaysiaProfessor of Medicine, Head of Gastroenterology and Hepatology, Universityof Malaya, Kuala Lumpur.E.V. Gomez, CubaDirector of Research, National Institute of Gastroenterology, Havana.R. Jackson, AustraliaPaediatric Gastroenterologist, Prince Of Wales Private Hospital, Sydney.S.S. Jhangiani, USAAttending, Departments of Internal Medicine, Gastroenterology and ClinicalNutrition, Montefiore Medical Center, New York.Assistant Professor of Medicine, New York Medical College, Valhalla, New York.Founder and Chairman, and Chairman, Doctors for a Healthier Bronx. lyJ.C. Joshi, IndiaConsulting Gastroenterologist and Hepatologist, Samvedana Clinic, Jolly onCentre, Mumbai. sA. Karstaedt, South Africa geDivision of Infectious Diseases, Department of Medicine, Chris HaniBaragwanath Hospital and the University of the Witwatersrand, paJohannesburg.S.R. Lin, China ePeking University Third Hospital, Peking. plS. Nair, USA amProfessor of Medicine, Medical Director of Liver Transplantation, Universityof Tennessee Health Science Center, Memphis. S
  14. 14. ABOUT THE CONTRIBUTORS XIIIC.J. Ooi, SingaporeHead and Senior Consultant, Department of Gastroenterology andHepatology, Director, Inflammatory Bowel Disease Centre, SingaporeGeneral Hospital.Associate Professor, Duke-NUS Graduate Medical School.Clinical Associate Professor, Yong Loo Lin School of Medicine, NUS.H. Paradwala, IndiaConsulting Physician, Saifee Hospital and Prince Aly Khan Hospital, Mumbai.N.Y. Pathak, IndiaSenior Research Fellow, Medical Research Centre, Kasturba Health Society,Mumbai.C.S. Pitchumoni, USAClinical Professor of Medicine, Robert Wood Johnson School of Medicine,New Brunswick, New Jersey.Chief of Gastroenterology, Hepatology and Clinical Nutrition, Saint Peter’sUniversity Hospital, New Brunswick, New Jersey.A.A. Rani, IndonesiaHead, Division of Gastroenterology, Department of Internal Medicine,Faculty of Medicine, University of Indonesia, Jakarta.D.N. Reddy, IndiaChairman, Chief Gastroenterologist, Asian Institute of Gastroenterology,Hyderabad, Andhra Pradesh.S. Riordan, AustraliaProfessor of Medicine, Head of Department of Gastroenterology andHepatology, Prince of Wales Hospital and the University of New South lyWales, Sydney. onS.K. Sarin, IndiaProfessor and Head of Department of Hepatology, Institute of Liver and sBiliary Sciences, New Delhi. geI. Segal, AustraliaGastroenterology Division, Prince of Wales Hospital, Sydney. paS. Shah, India ePrevious Head of Department of Gastroenterology, Sir J.J. Hospital, and plGrant Medical College Honorary Gastroenterologist at Jaslok, Saifee andBreach Candy Hospital, Mumbai. am S
  15. 15. XIV ABOUT THE CONTRIBUTORSP. Sharma, IndiaAssistant Professor, Department of Hepatology, Institute of Liver and BiliarySciences, New Delhi.O. Shrivsatav, IndiaConsultant, Infectious Diseases and HIV Medicine, Sir H.N. Hospital, JaslokHospital, Saifee Hospital, Specialty Clinics, Breach Candy Hospital, UnitHead, Kasturba Hospital for Communicable Diseases, Mumbai.D. Singhal, IndiaDepartment of Gastroenterology and Gastrointestinal Surgery, PushpawatiSinghania Research Unit for Liver, Renal and Digestive Diseases, New Delhi.E.A. Soler, CubaGeneral Director, National Institute of Gastroenterology, Havana.J.D. Sollano, PhilippinesProfessor of Medicine, University of Santo Tomas, Manilla.J. Sung, Hong Kong, ChinaPresident of the Chinese University of Hong Kong (CUHK) and Mok Hing YiuProfessor of Medicine.R.K. Tandon, IndiaDepartment of Gastroenterology and Gastrointestinal Surgery, PushpawatiSinghania Research Unit for Liver, Renal and Digestive Diseases, New Delhi.S. Tejavanija, ThailandMedical Staff, Department of Endocrinology and Clinical Nutrition,Phramongkutklao Hospital, Bangkok.K.T. Thia, SingaporeConsultant, Gastroenterology and Hepatology, Inflammatory Bowel Disease lyCentre, Singapore General Hospital. onR. Toney, USASenior Gastroenterology Fellow, Allegheny General Hospital, Drexel sUniversity College, Division of Gastroenterology, Hepatology and Nutrition, geDepartment of Medicine, Pittsburgh. paJ. Tu, AustraliaClinical Research Fellow, Gastrointestinal and Liver unit, Prince of WalesHospital, Sydney. e plA.D.B. Vaidya, India amResearch Director, ICMR Advanced Centre of Reverse Pharmacology inTraditional Medicine, Medical Research Centre, Kasturba Health Society,Mumbai. S
  16. 16. ABOUT THE CONTRIBUTORS XVS.W. Wong, AustraliaSenior Lecturer, Colorectal Surgeon, Prince of Wales Hospital, University ofNew South Wales, Sydney.J.C.Y. Wu, Hong Kong, ChinaProfessor, Institute of Digestive Disease, Chinese University of Hong Kong.S.D. Xiao, ChinaShanghai Renji Hospital, Shanghai Jiaotong, University School of Medicine,Shanghai Institute of Digestive Diseases, Shanghai. ly on s ge pa e pl am S
  17. 17. AcknowledgmentsGastroenterology and hepatology continue to progress at an acceleratingpace. Exciting new advances in techniques, treatments, diagnostic strategiesand positive research outcomes have resulted in a new world for medicalpractitioners. A silent ripple has spread like a global tsunami that has made a term like‘Western diseases’ obsolete. Obesity, inflammatory bowel disease, gastro-oesophageal-reflux disease, colorectal cancer and other Western diseases arenow common in the burgeoning emerging populations of India, China andother Asian and Pacific rim countries. We have been fortunate to have the commitment of internationallyrenowned experts from around the world to address the global presentationof these diseases in their various geographic regions. These invitedcontributors are at the cutting edge of both research and clinical aspects ofgastroenterology and hepatology and are able to provide an unprecedentedinsight into the global phenomena of the diseases. The editors are honoured by the excellence of the work of theseinternational authors, who have been partners in a sometimes difficultprocess. They have generously continued to give their time and energy inorder to ensure the success of the book. We believe the book may serve to bridge current knowledge for students,trainees, medical practitioners and researchers in digestive diseases. The format of the publication facilitates ease of access to the specificinformation required by users. In addition to the core text, chapters alsoinclude key points, tables, summaries and recommended reading. ly The editors are enormously indebted to the dedicated team at McGraw-Hill for their guidance, patience and zest in getting the book to press. In onparticular we are very grateful to Fiona Richardson, who was the driving forcebehind the scenes and who encouraged the enthusiastic participation of the sother team members. We are most grateful to Lizzy Walton, Ross Blackwood geand Yani Silvana for being part of this creative team and for their professionalinterest in the provision of a distinctive book. pa Isidor Segal, C.S. Pitchumoni and Joseph Sung e pl am S
  18. 18. Chapter 2: A globalphenomenon: medicinewithout frontiersI. Segal (Australia)Key points Climate change. Urbanisation. Xenobiotics: smoking, alcohol, volatile hydrocarbons, occupational disease, exposure to low-dose ionising radiation and air pollution. Dietary changes: obesity and junk food. Exercise trends. Introduction This is perhaps the most beautiful time in human history; it is really pregnant with all kinds of creative possibilities made possible by science and technology which now constitute the slave of man—if man is not enslaved by it. Dr Jonas Salk (1914–1995), developer of the polio vaccine.Globalisation has shifted the course of medicine. There are no longer anysharp divisions between geographical regions in terms of the prevalence andtypes of disease to be found in them: it is becoming more difficult to labeldiseases in terms of their geographic location. Environmental, economic,technological and social changes are evolving so rapidly in the twenty-first lycentury that a paradigm shift is needed in order to categorise diseases thatpreviously were restricted by geographical location. on The following discussion focuses on factors contributing to thesechanges: climate change, urbanisation, xenobiotics, dietary changes and sexercise trends. geClimate change paThe dynamics of disease patterns are changing due to climate change.In many places the Earth’s temperature is rising; some have predicted that the eaverage global temperature will rise by 3 to 7 degrees by 2100. pl Warming is escalating, and significant rises have occurred in recent amdecades. Human activities enhance the natural greenhouse effect bygenerating greenhouse gases that trap heat in the atmosphere. If this S
  19. 19. CHAPTER 2: A GLOBAL PHENOMENON: MEDICINE WITHOUT FRONTIERS 5continues at or above the current rate, average global temperatures arepredicted to continue to rise, bringing significant long-term effects for people,the environment and disease patterns. Burning fossil fuels such as coal, natural gas and oil for powering factories,industrial plants, home environments and cars, along with continuedtree-clearing for extended building development as populations increase, K CK FLICall exacerbate greenhouse gas problems.1 Health conditions are most susceptible to changes in climate, particularly 2in the very young, the very old or those with heart and respiratory problems. UI QChange also affects microbial contamination pathways and transmissionmechanisms such that water-borne, food-borne, rodent-borne andvector-borne diseases increase, especially malaria and diarrhoeal diseases. If temperatures rise 2 to 3 degrees Celsius by 2030, as some predictionsmaintain, the risk of malaria would increase by between 3 and 5 per centand diarrhoeal diseases would increase by 10 per cent. The latter wouldparticularly affect children, among whom mortality and morbidity fromdiarrhoea is already high in some developing countries. An example of thisis seen in the spread of malaria to the previously malaria-free region of theEastern Highlands of Kenya, where warmer, wetter weather has resulted inhigh rates of illness and death.2 McMichael et al. cite the known and probable health hazards of climatevariability and health change. They include temperature extremes, moredaily death events and disease events due mainly to very hot days and theeffects of floods, with more injuries, deaths and resultant infectious diseases,mental health disorders, increased allergic disorders and greater risk ofdiarrhoeal diseases, especially salmonellosis (poisoning by contaminatedfood).3 The risk of water-borne infections such as cholera may increase, and theincidence of mosquito-borne infections tends to increase with warming andchanges in rainfall; similarly, tick-borne infections may increase. ly Recent climate change has already contributed to altered food yields in onsome regions, causing changes in temperature, rainfall, soil moisture, pestactivity and plant disease that have reduced food production and increased sthe risk of malnutrition. It is evident that swift and aggressive international geaction is required to deal with the situation. paUrbanisationAsia is the most rapidly urbanising continent. Between 1970 and 1990 ethe world’s urban population rose by 1038 million, of which Asian cities placcounted for 589 million (56%). At the current rate, in China 870 millionpeople—more than half the projected population—will be living in cities amwithin less than a decade.4 S
  20. 20. 6 SECTION 1 | AN OVERVIEW In 2008 the proportion of the world’s population living in urban areascrossed the 50 per cent mark. Most observers believe that essentially allpopulation growth from now on will be in cities. The transition is happeningchaotically, resulting in unorganised urban landscapes in which many ofthe poorest people are rapidly absorbed into urban slums. Urbanisation is ahealth hazard for certain vulnerable populations, and this demographic shiftthreatens to create a humanitarian disaster. The threat comes both in theform of rising rates of endemic disease and a greater potential for epidemicsand even pandemics. Most people who relocate to cities are in search of employment. Manyfind that their only option is to live in dense, unplanned, illegal settlementslacking basic public infrastructure. These slums make up an increasingproportion of some growing cities. Increased population density in urbanareas that lack proper water supply and sanitation magnifies the risk ofcommunicable diseases being transmitted. Poor urban areas readily becomebreeding grounds for emerging infections and potential pandemics. Althoughslum residents may live close to health care providers, they generally havelittle access to high-quality care. Fundamental public health-related services,such as a safe water supply, sanitation and oral rehydration therapy, remainimportant. As the world becomes increasingly urban, the health of the urbanpoor may suffer and the stage could be set for devastating pandemics ofinfectious disease.5 In addition to these growing problems, rapid and unplanned urbanisationhas important ramifications with regard to urban pollution and health due toinadequate drainage and solid waste services, poor urban and industrial wastemanagement, air pollution (especially from particulates) and overcrowding,as well as such factors as depletion of water and forest resources. Asia’s economic growth is expected to continue. In order to achievesustainable development there will be an enormous need for wastedisposal facilities, roads, ports, power plants, water mains, airports and lycommunication systems. The issue of access is important and the cost of oninfrastucture will be trillions of dollars. The quality of education among the marginalised poor is variable and sgenerally of a low standard. Access to health care is also low in poorer areas gewith overcrowded poor-quality housing, lacking potable water and withsubstandard sanitation. pa In sub-Saharan Africa the traditional rural population is rapidly moving tocities; more than half of the population of approximately 700 million already elive in urban areas. pl UN-Habitat, the United Nations Human Settlements Program, has statedthat Africa’s chaotic urbanisation, together with the HIV/AIDS pandemic, amwas the biggest threat to the world’s poorest continent. It was estimated that,by 2000, 51 per cent of Africans would be living in cities and towns, and S
  21. 21. CHAPTER 2: A GLOBAL PHENOMENON: MEDICINE WITHOUT FRONTIERS 7Africa would cease to be a rural continent. In the more developed countries,84 per cent of the inhabitants will be urban dwellers by 2030.6 In agreement with this, according to a new report issued by the UnitedNations Population Division, virtually all population growth expected in thenext 30 years will be concentrated in urban areas. By 2030 the worldwidepopulation living in urban areas is projected to reach 60 per cent.7 K CK FLICXenobiotics 2Xenobiotics are substances foreign to living systems. The term includes drugs, UI Qpesticides, pollutants, carcinogens, volatile petrochemicals, food additivesand polluted working environments. The following discussion focuses onsome of the important xenobiotics.SmokingSmoking is a risk factor for many diseases. Lung cancer is the most serious,but other lung conditions such as chronic airways disease and emphysemaare also related to smoking, which has been identified as the second mostimportant risk factor for death from any cause worldwide. China, with apopulation of 1.3 billion, is the world’s largest producer and consumerof tobacco and a large proportion of deaths in China are attributable tosmoking. It had also been predicted that smoking would cause approximately930 000 adult deaths in India by 2010, mainly from tuberculosis andrespiratory disease in both men and women, and from heart disease andcancer in men. The three leading causes of death attributable to smoking in theUnited States are cancer, cardiovascular disease and respiratory disease inmen and respiratory disease in women.8AlcoholAlcohol abuse causes 3.5 per cent of all deaths and disability in the world, lyand its impact is more than five times as significant as illegal drugs on onhuman health globally.9 Alcohol consumption in South-East Asia is rising, particularly among syouths and young adults in both rural and urban areas. This may be due to geeconomic growth, increasing trade liberalisation and globalisation. Manycountries in Asia, including India, Sri Lanka, Malaysia and Thailand, cannot paprovide accurate consumption figures since local cheap illicit brews areconsumed in unknown quantities.10 e It is common knowledge that alcohol leads to health-related and social plproblems. In the digestive system alcohol is a leading cause of cirrhosis andpancreatitis and is also related to cancers of the mouth, oropharyngeal, amesophageal, liver and colorectal cancer. Diabetes is also implicated in thedisease pattern. S
  22. 22. 8 SECTION 1 | AN OVERVIEWVolatile hydrocarbonsA 1998 study carried out in Soweto, South Africa, suggested that exposureto volatile hydrocarbons, particularly petrochemicals, increases susceptibilityto pancreatitis.11 Braganza et al. had also earlier suggested that occupationalexposure to volatile hydrocarbons may be related to idiopathic and alcohol-related pancreatitis.12 Chronic exposure to xenobiotics such as smoke from coal fires andkerosene fumes from Primus stoves, along with long-term alcohol abuseand smoking, were cited as major contributing causes of pancreatitis. Bothacute and chronic pancreatitis appear to be endemic among the Sowetopopulation. Case control studies all identified the same three environmentalfactors in each disease: heavy alcohol consumption, marked exposure toindustrial chemicals and a low intake of fruit, which is a major source ofvitamin C.Occupational healthPeople in various occupations may be exposed to xenobiotic substances thathave serious deleterious effects on health. It has been suggested that there isan association between breast cancer and workshop exposure. The authorsbelieve that it is worth exploring exposure to chemicals metabolisedinto reactive chemicals such as organic solvents and rubber and plasticchemicals.13 Occupations cited as having possible links with chronic pancreatitis andpancreatic cancer include employment in automobile engine and partsmanufacture, service and maintenance, as well as dry cleaning, catering,cooking and serving, gasoline production, glue manufacture, oil refining,petrochemical industries and steel manufacture.14Exposure to low-dose ionising radiationImaging procedures are an important source of exposure to ionising radiationand can result in high cumulative effective doses of radiation, which have lybeen linked to the development of solid cancers and leukaemia. Thus the ongrowing use of medical imaging procedures has resulted in the risks ofradiation exposure becoming relevant.15 s It has been reported that the per capita dose of radiation from medical geimaging in the United States has increased by a factor of nearly six sincethe early 1980s, the largest contributors to total effective doses being X-ray pacomputed tomography (CT) scans and nuclear imaging, most of whichoccurred in outpatient settings. The United States has the world’s highest per ecapita imaging rate; as many as two per cent of cancers may be attributable plto radiation exposure during CT scanning. Radiation-induced cancer might not appear for years. While the danger amfrom individual scans may seem to be small, the effect is cumulative, so thatexposure to even moderate degrees of medical radiation is an important S
  23. 23. CHAPTER 2: A GLOBAL PHENOMENON: MEDICINE WITHOUT FRONTIERS 9yet potentially avoidable public health threat—one should be aware of thepotential for radiation-induced carcinogenesis.16Air pollutionAir pollution is an important cause of increased morbidity and mortalityworldwide. It has been suggested that sustained reduction of fine-particulateair pollution exposure would result in improved life expectancy.17 K CK FLIC 2Dietary changes UIWestern influences and modernisation of lifestyle in Asian populations has Qresulted in an alarming increase in the prevalence of obesity, both in childrenand adults.ObesityThe health risks associated with increased prevalence of obesity, particularlytype 2 diabetes, have also shown a similar increase. Other diseases associatedwith the obesity metabolic syndrome that have also indicated this patterninclude cardiovascular disease, hypertension, gallstones and certain cancers. The health risks associated with obesity in Asian countries occur at alower body mass index (BMI) than that observed in Western populations.This suggests that the current World Health Organization (WHO) criteriafor defining ‘overweight’ and ‘obese’ using BMI may not be appropriate forsome populations in the Western Pacific region. In addition, the patternof metabolic disease differs in Asians, who tend to preferentially increaseabdominal fat. Pacific Islanders tend to be prone to diabetes at greaterBMIs. It is notable that obesity and under-nutrition occur side by side within thesame population in some developing countries. Specific populations affectedby the obesity epidemic include China, India, Japan, Korea, Malaysia,Singapore, Taiwan, Thailand and the Philippines.18 lyJunk food onThere has been a marked increase in childhood obesity both in developedand developing countries. Parallelling this has been a great increase of sfood advertising in the media, particularly on television programs targeting gechildren. Television has been singled out as the most easily modifiableinfluential factor on diet. A survey carried out in six Asian nations—India, paIndonesia, Malaysia, Pakistan, South Korea and the Philippines—showed,for example, that 30 per cent of Malaysian children watch over eight hours eof television daily during holidays, exposing them to more than two and a plhalf hours of advertisements a day. A similar trend, although not as marked,was observed in the other countries surveyed; of these, only South Korea amand the Philippines have legislation regulating the advertising of fast food andconfectionery. S
  24. 24. 10 SECTION 1 | AN OVERVIEW Child obesity has reached epidemic proportions in some countries and ison the increase in others. Approximately 17.6 million children five years andunder are estimated to be overweight worldwide. This trend has spread from the developed to the developing nations.The long-term prognosis of this obesity epidemic is poor health with anincreased risk in adulthood of premature death from heart disease, and earlyonset of diabetes and certain cancers. These can no longer be regardedas Western diseases. A WHO report has emphasised that the incidenceof cardiovascular diseases has rapidly increased in India and China. Theincidence of diabetes is expected to rise 20 per cent worldwide over the nexttwo decades. This trend is partly due to obesity, unhealthy diets and sedentarylife styles. South-East Asia is witnessing the fastest spread of the epidemic. InIndia and China the incidence is projected to rise by 50 per cent within thenext two decades, affecting younger people than in the developed countries.18 This trend is known as ‘the nutrition transition’. Interestingly, nutritionproblems in Asia cover the entire spectrum from diseases due to deficiencyto those due to excess. Global availability of cheap vegetable oils and fats hasresulted in greatly increased fat consumption among low-income nations. As thenutrition transition has progressed, diets containing traditional root vegetablesand coarse grains are being replaced by refined rice and wheat along with otherfood products containing a greater proportion of dietary fats and sweeteners.19 Television is the most powerful variable influencing child obesity,contributing to it by two mechanisms: it reduces energy expenditure throughlowered physical activity at the same time as it increases dietary energyintake, either during viewing or as a result of advertising. It has been observedthat the greater a child’s advertising exposure the more frequently snackingoccurs and the lower the child’s nutrient efficiency. Most food advertisingaimed at children is for foods and beverages high in sugars, fat and/or salt.Exercise lyMany countries throughout the world are facing an increased incidence onof chronic diseases involving the cardiovascular, pulmonary and skeletalsystems, and cancer. Obesity and Type 2 diabetes are reaching epidemic sproportions. Regular exercise has been shown to reduce the risk for all of gethese diseases. It has been emphasised that regular physical activity hasnumerous health benefits and is an essential component of a healthy lifestyle. paAerobic activity in particular brings about health benefits.19 The above is in the context of surveys that show that about 30 per centof Americans are inactive (sedentary) in their leisure time, approximately e pl45 per cent are insufficiently active and only about 25 per cent are active atrecommended levels. Trends in leisure activity over time have been flat— amalthough there has been a gradual decline in the percentage of individualswho are inactive and a greater decline in older age groups.20 S
  25. 25. CHAPTER 2: A GLOBAL PHENOMENON: MEDICINE WITHOUT FRONTIERS 11 The recommended levels of exercise are at least 30 minutes ofmoderate-intensity physical activity on five or more days each week. Thisshould be integrated into a ‘lifestyle intervention’ program that integratesphysical activity into daily life.21 A study by Lorig et al. (1999) has suggested that intervention isfeasible and beneficial beyond usual care in terms of improved health K CK FLICstatus, and can decrease hospitalisation with a substantial savings inhealth care cost.22 2 UI Q SummaryIn conclusion, the breakdown of barriers to the spread of disease hasramifications that impact on global health and may signal what one mayexpect in the future. Awareness, adjustment and adaptability will be the keyto the practice of medicine worldwide. References1. United States Environmental Protection Agency. Climate change [internet]. Available from: Schuman EK. Global climate change and infectious diseases. N Engl J Med. 2010; 362(12):1061–3.3. McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet. 2006; 367(9513):859–69.4. Forbes D, Lindfield M. Urbanisation in Asia: lessons learned and innovative responses. Australian Agency for International Development; 1997.5. Patel BR. Urbanisation: an emerging humanitarian disaster. N Engl J Med. ly 2009; 361(8):741–3. on6. UN warns of urbanisation in Africa. IOL [internet] 2005 June 17. Available from: s ge7. UN Department of Economics and Social Affairs: Population Division [internet]. Available from: pa8. Dongfeng G, Tanika NK, Wu X, Chen J, Samet JM, Huang J, Zhu M, Chen J, Chen C-S, Duan X, Klag MJ, He J. Mortality attributable to e smoking in China. N Engl J Med. 2009; 360(2):150–9. pl9. Assunta M. Impact of alcohol consumption on Asia. The Globe 2001; am issues 3 & 4. S
  26. 26. 12 SECTION 1 | AN OVERVIEW10. World Health Organization South-East Asia Office. Alcohol consumption control—policy options in the South-East Asia region. Regional Committee 59th Session, Agenda Item 10, SEA/RC59/15 (Rev.2). 2006 22–25 August.11. Segal I. Pancreatitis in Soweto, South Africa. Digestion. 1998; suppl. 4:25–35.12. Braganza J, Jolly JE, Lee WR. Occupational chemicals and pancreatitis: a link?. Int J Pancreatol. 1986; 1:9–19.13. Labreche F. Occupations and breast cancer. Ontario Occupational Disease Panel [internet] 1997; Available from: htm/breastca.htm.14. Jeppe CV, Smith MD. Transversal descriptive study of xenobiotic exposures in patients with chronic pancreatitis and pancreatic cancer. Int J Pancreatol. 2008; 9:235–9.15. Fazel R, Krumholz HM, Wang Y et al. Exposure to low-dose ionising radiation from medical imaging procedures. N Engl J Med. 2009; 361(9):849–57.16. Lauer MS. Elements of danger: the case for medical imaging. N Engl J Med. 2009; 361(9):841–3.17. Pope CA III, Ezzati M, Dockery DW. Fine-particulate air pollution and life expectancy in the United States. N Engl J Med. 2009; 360(4):376–86.18. Inoue S, Zimmet P, Caterson I, Chunming C, Ikeda Y, Khalid AK, Kim YS, Bassett, J. The Asia–Pacific perspective: redefining obesity and its treatment. Regional Office for the WPRO, WHO, International Association for the Study of Obesity and the International Obesity Task Force. 2000.19. Escalante de Cruz A, Phillips S, Visch M, Bulan Saunders D. The junk food generation: a multi-country survey of the influence of ly television advertisements on children. Consumers International, on Asia Pacific Office, Kuala Lumpur [internet] 2004; Available from: . s20. Powers SK. Research in exercise science: a road map for the future. ge Arch Exerc Health Dis. 2010; 1(1):1–2.21. Buchner DM. Physical activity. Chapter 14. In: Goldman L, Ausiello D, pa editors. Cecil medicine. 23rd ed. Philadelphia: Saunders Elsevier; 2008, p.64–70. e pl22. Lorig KL, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease am self-management program can improve health status while reducing utilization and costs: a randomized trial. Med Care. 1999; 37(1):5–14. S