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WEO position statement on hygiene in digestive endoscopy: Focus on endoscopy units in Asia and the Middle East

Murdani A, Kumar A, Chiu HM, Goh KL, Jang BI, Khor CJ, et al.

Dig Endosc, 2017 Jan;29(1):3-15.
PMID: 27696514 DOI: 10.1111/den.12745

The aim of this position statement is to reinforce the key points of hygiene in digestive endoscopy. The present article details the minimum hygiene requirements for reprocessing of endoscopes and endoscopic devices, regardless of the reprocessing method (automated washer-disinfector or manual cleaning) and the endoscopy setting (endoscopy suite, operating room, elective or emergency procedures). These minimum requirements are mandatory for patient safety. Both advanced diagnostic and therapeutic endoscopies should be carried out in an environment that is safe for patients and staff. Particular attention is given to contaminants. Procedural errors in decontamination, defective equipment, and failure to follow disinfection guidelines are major factors contributing to transmission of infection during endoscopy. Other important risk factors include inadequate cleaning, use of older endoscopes with surface and working channel irregularities, and contamination of water bottles or irrigating solutions. Infections by multidrug-resistant organisms have become an increasing problem in health-care systems worldwide. Since 2010, outbreaks of multidrug-resistant bacteria associated with endoscopic retrograde cholangiopancreatography have been reported from the USA, France, Germany, and The Netherlands. In many endoscopy units in Asia and the Middle East, reprocessing procedures have lagged behind those of Western countries for cultural reasons or lack of financial resources. This inconsistency in standards is now being addressed, and the World Endoscopy Organization has prepared this position statement to highlight key points for quality assurance in any endoscopy unit in any country.
Fulltext Vitamin D deficiency causing eosinophilic esophagogastroenteritis and ascites: a rare association

Qua CS, Peh KB, Saravannan K, Goh KL

BMJ Case Rep, 2021 Feb 04;14(2).
PMID: 33541947 DOI: 10.1136/bcr-2020-240039

A 54-year-old Chinese man presented with ascites for 2 weeks. He had a preceding 2-year history of intermittent dysphagia, lethargy and general malaise. Blood investigations revealed leucocytosis with eosinophilia of 26.5%, whereas paracentesis showed turbid fluid with high protein content (45 g/L) and a high white blood cell count of 5580/µL, predominantly eosinophils (90%). An incidental assay of vitamin D showed a very low level of 13.5 ng/mL. No other cause of ascites was found. Gastroscopy was normal except for duodenitis. However, biopsies from lower oesophagus confirmed the presence of eosinophilic infiltration. Following vitamin D replacement, the patient experienced marked improvement in symptoms of dysphagia within 2 weeks and no recurrence of ascites after 3 months. The reason for the patient's vitamin D deficiency remains unclear. The marked improvement in the patient's health indicates a causative role of vitamin D deficiency in causing eosinophilic esophagogastroenteritis and associated eosinophilic ascites.
Variation in human genetic polymorphisms, their association with Helicobacter pylori acquisition and gastric cancer in a multi-ethnic country

Schmidt HM, Ha DM, Taylor EF, Kovach Z, Goh KL, Fock KM, et al.

J Gastroenterol Hepatol, 2011 Dec;26(12):1725-32.
PMID: 21649724 DOI: 10.1111/j.1440-1746.2011.06799.x

BACKGROUND AND AIM: The contribution of human genetic polymorphisms to Helicobacter pylori infection and gastric cancer (GC) development remains unclear due to geographic variation in the association between specific host genetic polymorphisms and GC. In the current study we investigated the association between polymorphisms related to immune and cancer-related pathways and H. pylori infection among the major ethnicities, Chinese, Malay and Indian, resident in Singapore and Malaysia as well as the association between these polymorphisms and GC development in ethnic Chinese patients.
METHODS: Thirty-four polymorphisms in 26 genes were typed by mass spectrometry in 422 patients undergoing endoscopy (162 Chinese, 113 Indian and 87 Malay controls and 60 Chinese GC cases). Patients were assessed for evidence of H. pylori infection. Odds ratios (OR) and confidence intervals (CI) were obtained using logistic regression models.
RESULT: The prevalence of 16 polymorphisms varied significantly among the ethnicities. In the Chinese subgroup, nominally significant associations were shown between (i) EBBR2+1963G (rs1801200) and H. pylori infection (per-allele OR: 0.48, 95% CI 0.23, 0.98, P = 0.04), (ii) PTGS2-1195G (rs689466) and an increased risk of GC on adjusting for H. pylori status (OR: 1.53, 95% CI 0.99, 2.37, P = 0.05), and (iii) IL1B-1473C (rs1143623) and a decreased risk of GC (OR: 0.64, 95% CI 0.41, 0.99, P = 0.05). Borderline significant associations were seen between IL2-330G (rs2069762) (OR 1.45, 95% CI 0.95, 2.15, P = 0.06) and IL13-1111T (rs1800925) (OR 0.65, 95% CI 0.42, 1.01, P = 0.06) and H. pylori infection.
CONCLUSION: These findings contribute to the understanding of the genetic variation between ethnicities, which may influence H. pylori susceptibility and the outcome of infection.
Validation study of the Leeds Dyspepsia Questionnaire in a multi-ethnic Asian population

Mahadeva S, Chan WK, Mohazmi M, Sujarita R, Goh KL

J Gastroenterol Hepatol, 2011 Nov;26(11):1669-76.
PMID: 21649731 DOI: 10.1111/j.1440-1746.2011.06806.x

BACKGROUND AND AIM:
Outcome measures for clinical trials in dyspepsia require an assessment of symptom response. There is a lack of validated instruments assessing dyspepsia symptoms in the Asian region. We aimed to translate and validate the Leeds Dyspepsia Questionnaire (LDQ) in a multi-ethnic Asian population.

METHODS:
A Malay and culturally adapted English version of the LDQ were developed according to established protocols. Psychometric evaluation was performed by assessing the validity, internal consistency, test-retest reliability and responsiveness of the instruments in both primary and secondary care patients.

RESULTS:
Between April and September 2010, both Malay (n=166) and Malaysian English (n=154) versions were assessed in primary and secondary care patients. Both language versions were found to be reliable (internal consistency was 0.80 and 0.74 (Cronbach's α) for Malay and English, respectively; spearman's correlation coefficient for test-retest reliability was 0.98 for both versions), valid (area under receiver operating curve for accuracy of diagnosing dyspepsia was 0.71 and 0.77 for Malay and English versions, respectively), discriminative (median LDQ score discriminated between primary and secondary care patients in Malay (11.0 vs 20.0, P<0.0001) and English (10.0 vs 14.0, P=0.001), and responsive (median LDQ score reduced after treatment in Malay (17.0 to 14.0, P=0.08) and English (18.0 to 11.0, P=0.008) to dyspepsia.

CONCLUSIONS:
The Malaysian versions of the LDQ are valid, reliable and responsive instruments for assessing symptoms in a multi-ethnic Asian population with dyspepsia.
Fulltext Use of probiotics in clinical practice with special reference to diarrheal diseases: A position statement of the Malaysian Society of Gastroenterology and Hepatology

Lee YY, Leow AH, Chai PF, Raja Ali RA, Lee WS, Goh KL

JGH Open, 2021 Jan;5(1):11-19.
PMID: 33490608 DOI: 10.1002/jgh3.12469

Probiotics comprise a large group of microorganisms, which have different properties and thus confer different benefits. The use of probiotics has shown promising results in the management of diarrheal diseases. While the availability of probiotic products has flourished in the marketplace, there is limited guidance on the selection of probiotics for clinical use. This position paper is aimed at informing clinicians about the proper selection criteria of probiotics based on current evidence on strain-specific efficacy and safety for the management of diarrheal diseases. Members of the working group discussed issues on probiotic use in clinical practice, which were then drafted into statements. Literature to support or refute the statements were gathered through a search of medical literature from 2011 to 2020. Recommendations were formulated based on the drafted statements and evidence gathered, revised as necessary, and finalized upon agreement of all members. Twelve statements and recommendations were developed covering the areas of quality control in the manufacturing of probiotics, criteria for selection of probiotics, and established evidence for use of probiotics in diarrheal diseases in adults and children. Recommendations for the use of specific probiotic strains in clinical practice were categorized as proven and probable efficacy based on strength of evidence. Robust evidence is available to support the use of probiotics for diarrheal diseases in clinical practice. Based on the results obtained, we strongly advocate the careful evaluation of products, including manufacturing practices, strain-specific evidence, and contraindications for at-risk populations when choosing probiotics for use in clinical practice.
Update on the management of Helicobacter pylori infection, including drug-resistant organisms

Goh KL

J Gastroenterol Hepatol, 2002 Apr;17(4):482-7.
PMID: 11982731

Helicobacter pylori infection has many different clinical outcomes. Not all infected persons need to be treated. Therefore, indications for treatment have to be clear, and several consensus guidelines have been formulated to aid the medical practitioner in this decision-making process. Triple therapy with a proton pump inhibitor (PPI), in combination with amoxicillin and clarithromycin is the established treatment of choice. For patients with penicillin hypersensitivity, metronidazole can be substituted for amoxicillin. Bacterial resistance to antibiotics is a major factor adversely affecting treatment success. Resistance to metronidazole has been reported in up to 80%, and resistance to clarithromycin in 2-10% of strains cultured. Resistance to either one of the antibiotics has been reported to result in a drop in efficacy of up to 50%. Emergence of resistance to both metronidazole and clarithromycin following failed therapy is a cause for concern; this underlines the need to use the best available first-line therapy. To avoid the emergence of resistance to both key antibiotics, the combination of metronidazole and clarithromycin should be avoided where possible. For failed treatment, several strategies can be employed. These include ensuring better compliance with repeat therapy, and maximizing the efficacy of repeat treatment by increasing dosage and duration of treatment, as well as altering the choice of drugs. Quadruple therapy incorporating a bismuth compound with a PPI, tetracycline and metronidazole has been a popular choice as a "rescue" therapy. Ranitidine bismuth citrate has been shown to be able to overcome metronidazole and clarithromycin resistance; it may be a useful compound drug to use in place of a PPI in "rescue" therapies. In the case of persistent treatment failures, it is useful to consider repeating gastroscopy and obtaining tissue for culture, and then prescribe antibiotics according to bacterial susceptibility patterns. It is also important in refractory cases to review the original indication for treatment and determine the importance of the indication.
Unmet treatment needs of gastroesophageal reflux disease in Asia: gastroesophageal reflux disease in Asia Pacific survey

Goh KL, Choi MG, Hsu WP, Chun HJ, Mahachai V, Kachintorn U, et al.

J Gastroenterol Hepatol, 2014 Dec;29(12):1969-75.
PMID: 24990817 DOI: 10.1111/jgh.12655

Data on patient satisfaction with proton pump inhibitor (PPI) therapy for gastroesophageal reflux disease (GERD) are scarce in Asia. The perspectives of Asian patients with GERD and their satisfaction with PPI therapy were investigated.
Ultrasonography-diagnosed non-alcoholic fatty liver disease is not associated with prevalent ischemic heart disease among diabetics in a multiracial Asian hospital clinic population

Chan WK, Tan AT, Vethakkan SR, Tah PC, Vijayananthan A, Goh KL

Clin Res Hepatol Gastroenterol, 2014 Jun;38(3):284-91.
PMID: 24736032 DOI: 10.1016/j.clinre.2014.02.009

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and cardiovascular diseases are both common among patients with diabetes mellitus.
OBJECTIVE: The aim of this study is to determine if ultrasonography-diagnosed NAFLD is associated with prevalent ischemic heart disease (IHD) among patients with diabetes mellitus.
METHODS: This is a cross-sectional study on consecutive patients seen at the Diabetic Clinic, University of Malaya Medical Centre. The medical record for each patient was reviewed for documented IHD. Patients without documented IHD but had symptoms and/or electrocardiographic changes suggestive of IHD were referred for cardiac evaluation.
RESULTS: Data for 399 patients were analyzed. Mean age was 62.8±10.5 years with 43.1% male. NAFLD and IHD were present in 49.6 and 26.6%, respectively. The prevalence of IHD among patients with and without NAFLD was 24.7 and 28.4%, respectively (P=0.414). The prevalence of IHD was highest among the Indians (34.1%) followed by the Malays (29.2%) and the Chinese (20.1%). No association was found between NAFLD and IHD when analyzed according to ethnicity. On multivariate analysis, independent factors associated with IHD were older age, lower levels of physical activity, greater waist circumference and higher serum glycated hemoglobin level.
CONCLUSIONS: Ultrasonography-diagnosed NAFLD was not associated with prevalent IHD among patients with diabetes mellitus in a multiracial Asian hospital clinic population.

Study site: Diabetic clinc, University Malaya Medical Centre (UMMC)
Ulcerative colltis in the older patient- a treatment conundrum

Goh KL

JGH Open, 2021 Aug;5(8):841.
PMID: 34386589 DOI: 10.1002/jgh3.12620
Ulcerative colitis in a multiracial Asian country: racial differences and clinical presentation among Malaysian patients

Tan YM, Goh KL

World J Gastroenterol, 2005 Oct 07;11(37):5859-62.
PMID: 16270398

AIM: Inflammatory bowel disease appears to be uncommon among Asians. This study was conducted to determine the prevalence of ulcerative colitis (UC) in Malaysian patients and to establish the spectrum of the disease seen in Malaysian patients. Three major Asian races: Malay, Chinese, and Indian co-exist in Malaysia and we sought to determine if there were any racial differences in the prevalence and presentation of disease. Racial differences for several other gastrointestinal diseases have previously been observed and found to be extremely interesting.
METHODS: Data were obtained retrospectively from a review of the medical records of in- and out-patients with a diagnosis of UC at the University Hospital, Kuala Lumpur between 1985 and 1998.
RESULTS: There were 45 confirmed cases of UC of which 3 were foreigners, who were excluded from analysis. Thirty new cases of UC were diagnosed during the study period. Their mean age at presentation was 33.0+/-10.0 years. The highest prevalence of UC was 17.9/100 000 hospital admissions in the Indians, followed by 11.2/100 000 hospital admissions in the Chinese. The lowest prevalence was 3.7/100 000 hospital admissions in the Malays. The prevalence of UC was significantly higher in the Indians and the Chinese when compared with the Malays with an OR of 4.89 (CI = 2.02-12.24; chi2 = 15.45, P<0.001) and 3.06 (CI = 1.24-7.78; chi2 = 6.30; P = 0.012) respectively. The extent of colonic disease was similar in the Malay and Indian patients. In contrast, distal or left-sided colitis predominated in the Chinese with an OR of 8.17 (95%CI = 1.31-64.87; chi2 = 5.53, P = 0.02). Extraintestinal manifestations were uncommon (11.9%).
CONCLUSION: UC is an uncommon disease in Malaysia, but racial differences exist. The Indians had the highest prevalence of UC with the Chinese demonstrating the least extensive disease.
Fulltext Ulcerative colitis in Malaysians

Jayalakshmi P, Wong NW, Malik AK, Goh KL

JUMMEC, 1996;1(2):39-42.

A review of all colonic biopsies received by the Department of Pathology during a 8-year period revealed 41 cases of ulcerative colitis (UC). The diagnosis was based on histological and clinical features. The age range of patients was between 14 - 76 years with a median age of 35.4 years. The disease was more prevalent among Indians. The common presenting sysmptoms were diarrhoea (100%) and haematochezia (83%). The extent of colonic involvement varied. Twelve patients (29.2%) had pancolitis and 8 (19.5%) had proctitis.Extraintestinal manifestations were rare and only one patient had pyoderma gangrenosum. One patient developed multifocal colorectal cancer 10 years after the inial diagnosis of UC and died 2 years later due to metastases. Histology plays an important role in the diagnosis and management of patients with UC. We noted a good correlation between clinical and pathological features. The most recent colonic biopsy showed features of chronic UC with activity in 34 cases and features of remission in 4 cases.
Fulltext Tumour seeding following percutaneous needle biopsy of hepatocellular carcinoma

Qua CS, Wong CH, Goh KL

Singapore Med J, 2008 Jan;49(1):e8-11.
PMID: 18204759

We report a hepatocellular carcinoma seeding following needle biopsy in a 57-year-old man who first presented with a focal hepatic lesion at another hospital. The patient had been a hepatitis B carrier for 20 years. Initial surveillance ultrasonography showed a lesion in segment IV, in the background of non-cirrhotic liver and normal serum alpha-foetoprotein level (8 ng/ml). A percutaneous needle biopsy was done and histopathology confirmed well-differentiated hepatocellular carcinoma. The patient had refused surgery and preferred to try traditional medicine. He presented to us four months after the initial biopsy with epigastric swelling. This was found to be due to a tumour seeding along the previous biopsy tract. He was given radiofrequency ablation (RFA) of tumour along the needle tract, in addition to the primary tumour. We conclude that the need for percutaneous needle biopsy should be critically evaluated in patients presenting with focal hepatic lesions and the role of RFA in treating tumour seeding needs further evaluation.
Tumour Lysis Syndrome: a Rare Complication of Trans-Arterial Chemo-Embolisation with Doxorubicin Beads for Hepatocellular Carcinoma

Katiman D, Manikam J, Goh KL, Abdullah BJ, Mahadeva S

J Gastrointest Cancer, 2012 Sep;43 Suppl 1:S187-90.
PMID: 22692948 DOI: 10.1007/s12029-012-9373-6
Tuberculous liver abscess

Goh KL, Pathmanathan R, Chang KW, Wong NW

J Trop Med Hyg, 1987 Oct;90(5):255-7.
PMID: 3669128

Tuberculous liver abscess is uncommonly seen in our experience. We report a case of a 17-year-old boy who presented with typical clinical features of liver abscess, where a diagnosis of tuberculous liver abscess was made on laparotomy and biopsy of the abscess wall.
Transnasal endoscopic placement of nasoenteric feeding tubes: outcomes and limitations in non-critically ill patients

Mahadeva S, Malik A, Hilmi I, Qua CS, Wong CH, Goh KL

Nutr Clin Pract, 2008 Apr-May;23(2):176-81.
PMID: 18390786 DOI: 10.1177/0884533608314535

Transnasal endoscopic placement of nasoenteric tubes (NETs) has been demonstrated to be useful in the critical care setting, with limited data on its role in non-critically ill patients. The authors collected data on consecutive patients from a non-critical care setting undergoing transnasal endoscopic NET placement. All NETs were endoscopically placed using a standard over-the-guidewire technique, and positions were confirmed with fluoroscopy. Patients were monitored until the removal of NETs or death. Twenty-two patients (median age = 62.5 years, 36.4% female) were referred for postpyloric feeding, with main indications of persistent gastrocutaneous fistula (n = 6), gastroparesis or gastric outlet obstruction (n = 5), duodenal stenosis (n = 6), acute pancreatitis (n = 4), and gastroesophageal reflux after surgery (n = 1). Postpyloric placement of NET was achieved in 19 of 22 (86.3%) patients, with 36.8% tube positions in the jejunum, 47.4% in the distal duodenum, and 15.8% in the second part of the duodenum. NET placement was least successful in cases with duodenal stenosis. NETs remained in situ for a median of 24 days (range, 2-94), with tube dislodgement (n = 3) and clogging (n = 5) as the main complications. NET feeding resulted in complete healing of gastrocutaneous fistulae in 5 of 6 patients and provision of total enteral nutrition in 3 of 4 cases of acute pancreatitis and 9 of 11 cases of gastroparesis or proximal duodenal obstruction. Transnasal endoscopy has a role in the placement of NET in non-critically ill patients requiring postpyloric feeding. However, there are some limitations, particularly in cases with altered duodenal anatomy.
Fulltext Transient unilateral pneumoparotid following upper endoscopy

Pillay Y, Goh KL

JUMMEC, 2014;17(2):12-13.
MyJurnal

Salivary gland swelling is a rare complication of upper endoscopy with less than twelve cases reported in the literature. The swelling is usually transient in nature, with complete resolution in a few hours .While all the major paired salivary glands have been implicated, the exact aetiology remains obscure. In this case report, a sixty one year old female presents with unilateral swelling of the right parotid gland immediately following an upper endoscopy. There was complete resolution of the pneumoparotid with no neurological sequelae.
Fulltext Transarterial embolisation of hepatocellular carcinoma with doxorubicin-eluting beads: single centre early experience

Nawawi O, Hazman M, Abdullah B, Vijayananthan A, Manikam J, Mahadeva S, et al.

Biomed Imaging Interv J, 2010 Jan-Mar;6(1):e7.
PMID: 21611067 MyJurnal DOI: 10.2349/biij.6.1.e7

This is a retrospective study to evaluate the results of our early experience of using doxorubicin eluting beads (DEB) to treat patients with early and intermediate hepatocellular carcinoma (HCC).
Fulltext Training programme in medical gastroenterology and hepatology: recommendations of the Malaysian Society of Gastroenterology and Hepatology

Kew ST, Goh KL, Zawawi M, Tan SS, Mohd R, Raj SM

Med J Malaysia, 1999 Sep;54(3):406-7.
PMID: 11045074
Fulltext Tolerance and safety to colonoscopy with conscious sedation in Malaysian adults

Ma WT, Mahadeva S, Quek KF, Goh KL

Med J Malaysia, 2007 Oct;62(4):313-8.
PMID: 18551936 MyJurnal

Tolerance to colonoscopy varies between populations and data from the South East Asian region is lacking. We aimed to determine tolerance and safety with to colonoscopy; conscious sedation and identify risk factors for complications in Malaysian adults. Consecutive outpatients undergoing colonoscopy were enrolled prospectively. A combination of pethidine and midazolam were used and tolerance to colonoscopy assessed three hours post-procedure using a validated scale. All patients were monitored for cardiorespiratory depression and risk factors for complications were identified. Two hundred and eight patients (mean age 57.2 +/- 14.8 years, 48% female) were enrolled. The population ethnicity consisted of 45 (21.63%) Malays, 101 (48.56%) Chinese and 56 (26.92%) Indians. Conscious sedation was achieved with 5.0 +/- 1.1 mg of midazolam and 43.3 +/- 14.0 mg of pethidine. Thirty (14.4%) patients tolerated the procedure poorly and independent predictors included female gender (OR 2.93, 95% CI = 1.22 to 7.01) and a prolonged duration of procedure (OR 2.85, 95% CI = 1.08 to 7.48). Hypotension occurred in 13 (6.25%) patients, with age > 65 years as the only risk factor (OR 13.17, 95% CI = 1.28 to 137.92). A prolonged duration was the main cause of hypoxia (OR 5.49, 95% CI = 1.54 to 19.49), which occurred in 6 (2.88%) patients. No major complications occurred during the study period. The current practice of conscious sedation is safe and tolerated well by most adults in our population. However, poor tolerance in a notable minority may have significant clinical implications.

Study site: Division of Gastroenterology, Department of Medicine, University Malaya Medical Centre (UMMC)
Fulltext Tobacco smoking and its association with illicit drug use among young men aged 15-24 years living in urban slums of Bangladesh

Kabir MA, Goh KL, Kamal SM, Khan MM

PLoS One, 2013;8(7):e68728.
PMID: 23935885 DOI: 10.1371/journal.pone.0068728

Tobacco smoking (TS) and illicit drug use (IDU) are of public health concerns especially in developing countries, including Bangladesh. This paper aims to (i) identify the determinants of TS and IDU, and (ii) examine the association of TS with IDU among young slum dwellers in Bangladesh.

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