Patients often have difficulty in describing abdominal pain. It can seem vague and hard to define. Or sometimes, it may be excruciating. Almost everyone has occasional abdominal pain caused by gas, constipation, diarrhea or other causes. A visit to a doctor is usually needed to determine the cause of severe or ongoing abdominal pain. Your doctor may use one of more of the several methods of evaluation to determine the cause and thereafter the best treatment/management. Some of these include blood or stool testing, scans (ie. CT, MRI, X ray, ultrasound, etc.), or endoscopic examination.

Some people feel that they pass too much gas or burp too frequently, both of which can be a source of embarrassment and discomfort. An average adult passes gas down the back side up to two dozen times per day. Burping occasionally before or after meals is also normal. The amount of gas produced by the body depends upon your diet and other individual factors. However, most people who complain of excessive gas do not produce more gas than the average person. Instead, they are just more aware of normal amounts of gas. On the other hand, certain foods and medical conditions can cause you to make excessive amounts of gas.

There are two primary sources of intestinal gas: gas that is ingested (mostly swallowed air) and gas that is produced by bacteria in the colon. Air swallowing is the major source of gas in the stomach. It is normal to swallow a small amount of air when eating and drinking and when swallowing saliva. However, you may swallow larger amounts of air when eating food rapidly, or with chewing gum and smoking. The colon or the large intestine is home to billions of harmless bacteria, some of which support the health of the bowel. Certain carbohydrates are incompletely digested by enzymes in the stomach and intestines, allowing bacteria to digest them. For example, cabbage, sprouts, and broccoli contain raffinose, a carbohydrate that is poorly digested. These foods tend to cause more gas and flatulence.

Barrett’s oesophagus is a condition that affects the lower oesophagus. In this condition, the normal cells in the lower part of their oesophagus are replaced by different type of cells. This is usually caused by long standing acid reflux. Most people with acid reflux never get Barrett’s oesophagus, but some do.

If you have had acid reflux for a long time, it’s important to know if you also have Barrett’s oesophagus. That’s because Barrett’s oesophagus can later turn into pre-cancer or cancer of the oesophagus.

The diagnosis of Barrett’s oesophagus can only be made on oesophago-gastro-duodenoscopy (OGD). The physician will examine the lower end of the oesophagus under special light and should be able to make a confident diagnosis. Biopsies may also be taken during the procedure to confirm the diagnosis.

Barrett’s oesophagus is treated by reducing or getting rid of a person’s acid reflux. Treatment does not usually cure Barrett’s oesophagus, but it keeps it from getting worse.

Your doctor will likely give you medicines to stop your stomach from making acid. He or she might also recommend that you:

• Avoid caffeine drinks, alcohol, chocolate, peppermint, and fatty foods. These foods can make acid reflux worse.
• Avoid eating before going to bed, eating large meals, or lying down after eating
• Raise the head of your bed by 6 to 8 inches

Celiac disease is a disorder whereby the body’s immune system (‘infection-fighting system’) attacks and causes injury/inflammation of the small intestine following the ingestion of gluten (a protein found in wheat, rye and barley). The damage of the small intestine will prevent the absorption of some nutrients, i.e. malabsorption. Patients with celiac disease may have belly discomfort, diarrhoea, weight loss, fatigue, anaemia (low red blood cell count) or an itchy skin rash.

Celiac disease can be confirmed by blood tests and on biopsies of the small intestine taken on oesophago-gastro-duodenoscopy (OGD). Samples of tissues are then examined under the microscope to confirm the disease. The only treatment for celiac disease is lifelong adherence to a strict gluten-free diet.

Gastro-oesophageal reflux disorder is a condition when the acid in the stomach flows up into the esophagus (gullet). The patient may complain of heartburn, chest pain, and acidic taste in the throat or an unexplained chronic cough. Some patients may feel a lump stuck in the throat.

Several factors may be involved in the causation of gastro-oesophageal reflux including:

• The ability of the lower sphincter muscle to open and close properly,
• The amount of stomach juices that travels up into the esophagus,
• The ability of the esophagus to clear the acid quickly and
• The neutralizing effect of saliva.

Diagnosis of GERD can be easily achieved based on the following:

• Symptoms such as those mentioned above.
• Oesophago-gastro-duodenoscopy (OGD) to visually examine the inside of your esophagus and stomach.
• A test to monitor the amount of acid travelling up in the oesophagus. Ambulatory acid (pH) probe tests use a device to measure acid for 24 hours. The probe transmits a signal to a belt that is worn during the duration of the test.
• Oesophageal motility testing (manometry) measures movement and pressure gradients in the esophagus. This test is useful in determining if abnormal movement of the esophagus is contributing to your symptoms.

Treatment involves simple lifestyle and dietary modifications which may help improve the symptoms. These may include losing weight for overweight patients, quitting smoking, cutting down on alcohol and avoiding certain foods (like chocolates, coffee, fatty meals, peppermint). In majority of patients however, medicines are still required to effectively control the reflux symptoms. In certain cases, the symptoms may persist and further tests may be needed.

Gastric or duodenal ulcer is a sore that forms on the lining of the stomach or duodenum (the first part of the small intestine). Some patients with this condition may have no symptoms, but most will have upper belly pain or discomfort. Common causes of gastric or duodenal ulcers are bacterial infection of the stomach or duodenum (the bacteria called ‘Helicobacter pylori’), and the pain-relieving medicines called ‘nonsteroidal anti-inflammatory drugs’ (NSAIDs).

Stomach and duodenal ulcers are usually diagnosed on oesophago-gastro-duodenoscopy (OGD). This procedure has been described in detail in another section.

Gastric or duodenal ulcers can be treated with medicines. If left untreated, serious complications may occur such as bleeding and perforation (a hole in the stomach or duodenal wall).

Gastric cancer, also known as stomach cancer, is a type of cancer that affects the stomach.

Patients with this condition may have gastric discomfort, sense of abdominal fullness after eating a small meal, heartburn, weight loss or anaemia (low red blood cell count). However, there are no specific symptoms which may point to the presence of stomach cancer straightaway. As with stomach or duodenal ulcers, gastric cancer is also diagnosed on an oesophago-gastro-duodenoscopy (OGD). Gastric cancer can be treated with surgery and/or chemotherapy, radiotherapy depending on the severity of the disease.

Helicobacter pylori (H. pylori) are bacteria that can infest the stomach. In most patients, H. pylori infection does not lead to any problem or symptoms. But in others, it may cause gastric or duodenal ‘ulcers’ of the stomach or duodenum. H. pylori have also been linked to the development of stomach cancer and lymphoma.

Some blood or breath tests are available to check for Helicobacter pylori infection. Oesophago-gastro-duodenoscopy’ (OGD) may also be used to confirm H. pylori infection and examine the lining of the stomach and duodenum. Samples of stomach tissue can then be taken to test for H. pylori infection. H. pylori infection can be treated with medicines. After treatment, the patient should have follow-up tests to check the infection has gone away.

Diarrhoea describes bowel movements that are runny or watery, and happen 3 or more times in a day. Diarrhoea is very common. Most adolescents and adults have diarrhoea about 4 times a year. Just about everyone has it at some point.

Diarrhoea may also be caused by:

• Infection by bacteria, viruses, parasites or other organisms
• Eating foods that upset the digestive system
• Food allergy
• Drugs and medicines
• Previous radiation therapy
• Diseases of the small or large intestine such as Crohn’s disease or ulcerative colitis)
• Malabsorption (where the body is unable to adequately absorb certain nutrients in the diet) such as Coeliac disease.
• Hyperthyroidism
• Certain cancers
• Laxative abuse

After listening to your history and examination, a diagnosis can usually be reached with simple blood and stool tests. Sometimes, a colonoscopy and/or oesophago-gastro-duodenoscopy (OGD) may be needed for further evaluation.

Polyps are small growths on the lining of the colon (large intestine). While most polyps are harmless, some are precancerous. Removing polyps during a colonoscopy before they can become malignant is a lifesaving procedure for millions of people all over the world. In Singapore, colon cancer is the most common cancer among men and second most common cancer in women (after breast cancer).

Unfortunately, many patients are not so lucky and are diagnosed with colon cancer. If caught early, colon cancer is over 90% curable. We cannot emphasize it enough – screening colonoscopies save lives.

The various risk factors for colon cancer are:

• Age – if you are 45-50 years old or above, you should be screened for colon cancer.
• Family History – if you have a first degree relative with colorectal cancer (parent, sibling, child) you should speak to a gastroenterologist in our team. Your screening schedule will be unique to you.
• Inflammatory Bowel Disease – ulcerative colitis and Crohn’s disease can increase your risk of developing colorectal cancers
• Lifestyle factors include – high fat diets, heavy smoking and heavy consumption of alcohol
• Obesity and lack of regular exercise.

Haemorrhoids are swollen veins in the rectum (the lower part of the large intestine). They are usually hidden inside, though in some people, it can be seen or felt around the anus. They may cause pain or itchiness, and not uncommonly they can cause bleeding while passing motion.

The most important treatment in haemorrhoids is to keep one from getting constipation which can make it worse. There are also medicines to relieve the swelling, pain and itchiness. In some cases, treatments such as ‘rubber band ligation’ or surgery may be needed.

Irritable bowel syndrome (IBS) is a condition that causes belly pain and problems with passage of poop. The belly pain or bloating sensation usually happens after meals. Some patients have diarrhoea, others may have constipation and some may switch back and forth between diarrhoea and constipation. There are no specific tests to diagnose IBS. But some tests may be needed to make sure that patients do not have other medical problems that can cause the same symptoms.

Medicines and counselling are the mainstay in the treatment of IBS. Dietary modification and a consultation with a nutritionist can be of immense help as well.

Inflammatory bowel disease (IBD) is a disorder that can cause diarrhoea, abdominal pain, bloody bowel movements and weight loss. The symptoms happen because the lining of the digestive tract becomes inflamed and gets sores (ulcers). The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now we know that these factors may aggravate but don’t cause IBD.

One possible cause is an immune system malfunction when an abnormal immune response causes the immune system to attack the body’s own cells in the digestive tract. Heredity also seems to play a role in that IBD is more common in people who have family members with the disease.

There are two main types of IBD – Ulcerative colitis and Crohn’s disease. The diagnosis is usually achieved by a colonoscopy and if needed a oesophago-gastro-duodenoscopy in conjunction with some scans and blood tests.

IBD can be treated with medicines (both oral and injections) and in more severe cases, surgery may be needed.

Bleeding from the rectum or the back side is not an uncommon problem and is often associated with defecation. This may be frankly visible, or mixed in with stool invisible to the naked eye. The color, quantity and frequency of bleeding, and presence of absence of abdominal pain may help your doctor to determine the cause of the bleeding.

Common causes of rectal bleeding are anal fissures, haemorrhoids, cancer of the rectum and colon, diverticulosis, abnormal blood vessels (angiodysplasia), ulcerative colitis, Crohn’s disease and colon infections. Rectal bleeding is one problem which you should never ignore.

After a proper and thorough examination of the abdomen and rectum, most of the times, a colonoscopy is needed to establish the diagnosis and also to treat the main problem.

Hepatitis B is a virus that can cause liver inflammation. The virus can spread from person to person through sexual contact or needle sharing or other body fluids. A pregnant woman can also pass the infection onto her baby during delivery. Patient with acute hepatitis B infection may have flu-like symptoms and jaundice (yellowish eyes and skin). They usually get better without any special medication. But around 5% of patients end up having the disease for a long time. This is called ‘chronic hepatitis B’. Most patients with chronic hepatitis B have no symptom. But over time, the infection can result in liver scarring, called ‘cirrhosis’ and complications such as belly swelling, leg swelling, confusion may happen. Patients with chronic hepatitis B also have an increased risk of getting liver cancer.

Blood tests can be done to confirm the hepatitis B infection. For patients with chronic hepatitis B infection, medicine may be needed to fight the virus and to prevent liver scarring and liver cancer.

Hepatitis C is another virus that can cause liver inflammation. The virus can spread from person to person through needle sharing, contact with blood or sexual contact. A pregnant woman can also pass the infection onto her baby during delivery.

Most patients with hepatitis C infection have no symptoms, although some may feel lethargy and have jaundice (yellowish eyes and skin).  Most patients end up having the disease for a long time. This is called ‘chronic hepatitis C’. Over time, the infection can result in liver scarring, called ‘cirrhosis’ and complications such as belly swelling, leg swelling, confusion may happen. Patients with chronic hepatitis C and liver scarring have an increased risk of getting liver cancer.

Blood tests can be done to confirm the hepatitis C infection. For patients with chronic hepatitis C infection, medicine may be needed to fight the virus and to prevent liver scarring and liver cancer. With the currently available medicines, hepatitis C can be completely cured in more than 95% of the patients.

Hepatocellular carcinoma (HCC) is one of the common cancers afflicting the liver. The most common liver cancer still remains one which has spread to the liver from other parts of the body (metastatic cancer). Most patients with HCC have long term hepatitis B infection or long term scarring of the liver, called ‘cirrhosis’. HCC itself may not cause any symptom. Some patients may have pain or lump in the right upper belly. Others may have symptoms of liver cirrhosis such as abdominal swelling, leg swelling, jaundice (yellowish eyes or skin), confusion and bleeding from the swollen blood vessels in the oesophagus.

Blood tests and imaging tests such as ultrasound scan or CT scan can be performed when HCC is suspected. In some patients, a test called ‘liver biopsy’ may be needed. HCC can be treated in different ways depending on the stage of the cancer.

Liver cirrhosis is scarring of the liver. Scar tissue forms because of long term liver injury. Some people with early cirrhosis have no symptoms but as the disease progresses, symptoms such as belly swelling, leg swelling, jaundice (yellowish eyes or skin), confusion and bleeding from the swollen blood vessels in the oesophagus may happen. Patients with cirrhosis also have an increased risk of getting liver cancer.

There are a wide range of causes of liver cirrhosis. The common causes include heavy alcohol use, hepatitis B infection, hepatitis C infection, non-alcoholic fatty liver disease, and the less common autoimmune liver and metabolic liver disorders. Blood tests and imaging test such as ultrasound scan are used to confirm and further assess the patients with cirrhosis. In some occasions, a test called ‘liver biopsy’ may be needed. In this test, a needle will be inserted into the liver and a small sample of tissue will be taken for examination under the microscope.

Treatment of cirrhosis includes treatment of the underlying causes. Medicines can be prescribed to reduce the fluid build up in the body and lower the risk of bleeding from the lower end of the oesophagus (if they occur). In some patients, a procedure called ‘variceal band ligation’ may be needed to prevent or stop the bleeding. This procedure introduces a thin tube with an attached camera through the mouth and down into the oesophagus. Tiny bands are then tied around the swollen blood vessels in the lower end of the oesophagus.

In patients with severe liver cirrhosis, liver transplantation is an option and should be considered.

Non-alcoholic fatty liver disease (NAFLD) is a condition when excessive fat tissue builds up in the liver of people who do not drink alcohol or drink only a little alcohol. This is very common in people who are overweight or have medical problems such as diabetes, high blood pressure or high cholesterol.

Most people with NAFLD have simple fatty liver that is relatively benign and have no symptoms. But in some cases, it can cause liver inflammation and lead to liver scarring and liver cancer. Blood tests and imaging test of the liver such as ultrasound scan can be performed if NAFLD is suspected.

Treatment of NAFLD includes weight loss, regular exercises, controlling of high blood sugar, high cholesterol and high blood pressure. Newer medicines which are now available may be recommended in certain group of patients with fatty liver.

A wide range of disease afflicts the gallbladder, pancreas, and bile ducts. Bile juice aids the digestion and absorption of fats and is carried from the liver to the small intestine by the bile ducts. The gallbladder stores the bile between meals and empties it back into the bile duct, once food is consumed. Another duct allows digestive juices from the pancreas to mix with food in the intestine. Both the bile duct and the pancreatic duct open in the small intestine at the same point. Problems in these organs and passageways include infection, blockages, stones, and cancer.

At Asia Digestive Associates, we can carry out a procedure known as endoscopic retrograde cholangiopancreatography (ERCP) to diagnose and treat these problems. ERCP involves placing an endoscope into the mouth through the esophagus and stomach into the duodenum (part of the small intestine).

The various diseases which may affect the gall bladder, bile ducts and pancreas include Bile duct injuries or strictures, bile duct stones, inflammation of the gall bladder, gall bladder stones, pancreatic and biliary duct cancers and pancreatitis.

These diseases can be diagnosed and sometimes treated by endoscopic retrograde cholangio-pancreatography (ERCP), Endoscopic ultrasound (EUS), magnetic resonance imaging (MRI) and may involve the use of plastic or metal stents, laser or other devices.