Monday, October 25, 2010


A 40 year old man came with 'letih-letih' and not feeling well for the past one month. Ultrasound examination done by a general practitioner showed a tumour on the left kidney. CT-scan done revealed a large tumour arising from the upper pole of the left kidney.

This is one of his CT-scan films; it showed a large tumour involving the left kidney. This is most probably a Renal Cell Carcinoma (RCC) - kanser buah pinggang.

He was told of the diagnosis, treatment and the prognosis with and without treatment.
Prognosis tu maksudnya apa akan jadi dengannya selepas ini termasuk mati.

He was offered surgery; as the cancer is still resectable and most probably curable.
And the expected happened; the Kelantanese syndrome. He disappeared, I hope temporarily.

5 years ago, I operated on a 33 year old man with similar cancer; he survived. Now happily married and last week called me to inform me that he just got a baby girl.
This is the picture of his cancer.

The cancer was well-encapsulated, the capsule wasn't breached by the cancer. No chemotherapy was given.

And these are CT-scan picture of other patient with similar cancer on the right side (see how huge it is) and the picture of the removed specimen.

She waited for three months before agreeing to the surgery.

See, the cancer had breached the capsule, she was given chemotherapy. Two and a half years later, she came back with bone and brain secondaries (kanser merebak ke otak dan tulang) and died soon after.

Kadang-kadang, saya tak faham dengan orang kita. Bila doktor kata kanser, dia mungkin dengar risa; buang tak apa, tak buang pun tak apa.

In Kelantan, risa (pronounced reeso) is a benign tumour of the skin or subcutaneous structures; it could be a lipoma, sebaceous cyst, ganglion, etc.

Monday, October 18, 2010


Pepatah Melayu :

Sudah terantuk baru tengadah
Hendak terberak baru nak gali lubang.

Inilah yang jadi kalau susah sangat nak faham

A 59 year old man, had fecal incontinence (tak boleh kontrol berak) two years ago. He went to a private hospital, told to have cancer of the rectum (usus besar dekat dubur) and adviced surgery. Refused, went to HUSM and told the same thing. Tak puas hati, went to Kota Bharu Hospital (HRPZII). Tak mahu faham juga.

He has cancer of the rectum, very close to the anus resulting in fecal incontinence (meaning the cancer has already involved the sphincter muscles). The surgery to the remove the cancer would also remove the sphincters. thus he would need a permanent colostomy.

Sebabkan tak mahukan colostomy, langsung tak mahu rawatan. Obviously, Tok Bomoh kata kolostomi tak perlu.

Two years sengsara pakai diapers. Now the cancer has totally oblitrated the rectum causing intestinal obstruction. Apa lagi, perut jadi kembung, tak boleh berak. Makanan masuk ikut mulut, tahi pun keluar ikut jalan yang sama.

Gambar X-ray usus besar kembung tiga kali ganda

Terpaksalah buat emergency operation. Sekarang bukannya nak buang kanser yang telah merebak (inoperable), tapi nak selamatkan nyawa, supaya boleh makan.

Grossly distended large intestine.

Akhirnya kena buat juga kolostomi juga. Now dah selamat; dah boleh makan dan berak melalui kolostomi.
Tapi kansernya tetap di situ.
AlhamdulilLah sekarang baru nak kemoterapi dan radioterapi. Tapi apakan daya !!!
Inilah cerita 'oghe kelate' ku.......


KOTA BARU: Three cases of breast cancer involving men were reported at Hospital Universiti Sains Malaysia (HUSM) in Kubang Kerian, here last year with one patient succumbing to the disease.
Coordinator of HUSM's breast cancer information centre, Dr Nik Munirah Nik Mahdi, said according to the last national cancer registry in 2006, six men in Kelantan had died of breast cancer."Breast cancer is seen more as a disease that affects women but it is not necessarily so. That is why it is important for people from both sexes to be well informed about it," she said after the launch of the information centre's blog and a workshop on women's health yesterday by the chairman of USM board of directors, Prof Emeritus Datuk Dr M. Zawawi Ismail. Read more: 6 Kelantan men die of breast cancer

Jadi jangan sangka barah payudara (breast cancer) hanya terkena pada wanita, yang jantan juga boleh kena. Unfortunately breast cancer in men tends to be more aggressive. I have seen a man with breast cancer presented with brain secondaries. Maksudnya datang dengan tanda-tanda barah otak, setelah disiasat didapati puncanya adalah barah payudara (dalam kes ini payu-jantan).
Jadi abang-abang tu jangan asyik nak buat BSE (breast self examination) pada isterinya saje, sendiri juga mesti rasa .......

Monday, October 11, 2010


Lunch time: I was joined by a radiographer (juru-Xray) asking me 'kenapa dah lama tak update blog doktor?' Tiba-tiba saya teringat.... dah lama tak buka blog ni ! mungkin sibuk dengan 'kegilaan' baru di facebook. So I said; OK saya pergi update sekarang jugak.
Just before the lunch hour, I was in the A & E Department; attending to a patient presented with cough and breathlessness. She was a 35 year old teacher, has been coughing since 2 months ago, went to Kuala Krai hospital yesterday and claimed the doctor there refused to give her any medication. When I came closer to her bed, I smelled something familiar; 'bila lagi dah ada penyakit ini?' 'Baru 2 bulan batuk-batuk ni'. 'Bukan batuk, your breast cancer?' 'Mana doktor tahu saya ada kanser?' ' I can smell it !
Reluctantly she exposed her self; and there you were... large left breast cancer with involvement of the contralateral breast. Jarang jumpa ni, kanser payudara kiri dan kanan serentak. I examined the lungs, and I told her that most probably the cancer has infiltrated her lungs as well. Suprisingly she suggested; mungkin infection doktor, TB ke.. beri saya ubat antibiotik je!
Unbelievable.... inilah sikap orang kita (oghe kelate kito) the big C is nothing. So, to made her understand the serious situation she is in, I told her ; Kalaulah cikgu ni Tok Wakil, selepas PRK Galas ni, kita pergi mengundi kawasan DUN awak pulak ........
Saya harap dia faham, her days are numbered !!

Sunday, August 22, 2010


A 50 year old man came to see a physician with severe anemia and difficulty in swallowing. He had these symptoms for the last five months. Associated with that he also noted that his stools were dark (malenic - meaning there is blood in it). And he gradually loss his weight; from an astounding 130 kg to less than 70 kg during these 5 months. He could not take anything solid.

His friends including a doctor neighbor had adviced him to seek treatment. He went to his usual bomoh and tukang urut and once to a homeopathic practitioner. Last week, he could not swallow anything and only then he saw the physician.

On examinaton he was grossly wasted and dehydrated, and pucat lesi (Hb 5.4 gm%). After transfusing him with 4 units of blood, the physician referred him to me for scope (OGDS). He initially refused (couldn't imaging having a camera being pushed down his throat!), but after convincing him that there wouldn't be any pain, I managed to do the procedure. There was an obstructing tumour in his esophagus. Biopsy showed a well-differentiated adenocarcinoma and the CT-scan showed :

A huge cancer in the lower end of the esophagus extending into the stomach ( or vice-versa) with metastatic nodes. There is a trickle of contrast going into the stomach.
So, now with an massive cancer (adenocarcinoma) in the esophago-gastric junction, 'inoperable'; he is left with not many options.
This type of cancer does not respond to radiotherapy, poor results with chemotherapy and surgery has high morbidity and mortality. As a palliative measure, a stent could be placed so that he would be able to take something orally.
And of course his days are numbered.
To make the thing worst; after talking to him many times, he didn't seem to understanding ......
Kelantan, oh Kelantan ku
or rather
oghe kelate, oghe kelate....gapo nak jadi ni?

Tuesday, August 10, 2010


A 55 year old man came to me for treatment of 'piles (buasir)'. He complained of passing out blood and mucus (lendir) during defecation, and lately the feeling of incomplete defecation (rasa berak tak puas). He had been seeing several doctors in his hometown for these symptoms, and all of them treated him with hemorrhoidal medications. None of them did a rectal examination.
When I examined him, there was an ulcerating tumour in the lower third of the rectum extending into the anal canal.
This is how it looks from the inside of the rectum (on colonoscopy). Anybody could have feel it if he sticks his finger into the rectum, but nobody did it. And the cancer was missed !
Anyway, after confirming the diagnosis with a tissue biopsy, I proceeded with surgery to remove the rectum (including the anus) and constructed him a permanent colostomy. This is the picture of the resected specimen.

The cancer can be seen very close to the anal skin.

This is the problem. A patient comes with very obvious symptoms, no proper assessment or examination done, yet, oh, you have buasir ! and a cancer is missed again until it's too late.

Susah sangatkah nak buat rectal examination ?

TERMENGANDUNG . . . . Apa nak buat ?

Termengandung - literally 'accidentally gets pregnant' - but I am not talking about unplanned pregnancy.
This is about a woman who was adviced NOT to get pregnant but somehow found herseft pregnant. Cancer patients undergoing chemotherapy or hormonal therapy are not suppose to get pregnant.
This women came to me with right breast cancer, and had a breast conservative surgery done. What it means is - only the cancer and the surrounding breast tissues were excised, and she still has the breast. For that she was referred to an oncologist for chemotherapy. She went around in KL and Penang (with my referral letter) meeting several oncologists to find one who would agree with her not to have the chemotherapy. Unfortunately she found none! All the oncologists she met insisted that she should have the chemo. Finally she accepted it; and the chemotherapy was started 4 months ago. After 3 months (3 cycles of chemotherapy) she found herself pregnant. Tiga bulan baru tahu dah mengandung, susahlah kawe nak explain, hok ni kena tanya orang pompuanlah ! The oncologist referred her to an obstetrician for abortion. She called me yesterday for advice as both her physicians are non-muslims and she needs to know whether the abortion (in this circumstance) is permitted in Islam.
I am not an expert in Fiqh (Islamic jurisprudence) but I told her what I undertand and adviced her to seek the advice of Tok-tok Guru or Ustaz and 'alim-ulamak'.
As a doctor, I explained to her why she was adviced not to get pregnant when she went for chemotherapy.
Chemotherapy is a form of cancer treatment using drugs / medicines (chemotherapeutic agents). The drugs 'kill' the cancer cells. Kalau awak ada cacing, makan ubat cacing. Maka cacing mati dan awak jadi sihat. If you have TB germs in your lungs, you take TB medicines' kuman TB mati dan you jadi sihat!. Cancer is different... the cancer cells are parts of your bady, they are not germs or cacing. So a drug that kill cancer cells also kill normal cells. Then, how to kill cancer cells without killing the patient? Cancer cells are fast dividing cells, thus chemotherapeutic agents (ubat chemo) are designed to target cells that divide fast; yang cepat tumbuh. Malangnya dalam badan kita, bukan sel-sel kanser saja yang tumbuh dengan cepat; ada juga anggota badan yang tumbuh cepat; misalnya rambut, kuku, sel-sel darah dan sebagainya. Sebab itu bila kena kemo, rambut habis gugur, kuku jadi hitam, sel darah merah berkurangan (anaemia) dan sel darah putih rendah (mudah kena jangkitan dan kadang-kadang pesakit kanser perlu reverse isolation).
Just imaging if you were pregnant ! The budding foetus and the fast dividing cells within it are killed by the chemo drugs. Samada janin tu mati (anda keguguran) atau kalau dia hidup, dia cacat dengan teruk sekali. So, in the case of this particular patient, I told her that the pregnancy might aborts spontanenously or if it manages to mature, she might give birth to a severely deformed baby - tapi Allah lah yang menentukannya dan Dia Maha Mengetahui dan Maha Menyayangi !
Bagi doktor-doktor, dan adik-adik yang belajar perubatan; berilah penerangan yang jelas setiap kali anda menerangkan sesusatu kepada pesakit. Jangan anggap semua orang mudah faham sesuatu seperti anda. Ada di antara pesakit kita (sorry to say) 'slow' sungguh !.
I'll tell you my experience last week. Ada satu orang yang saya buat operation membuang sebahagian ususnya kerana kanser usus. Hari pertama selepas pembedahan, saya benarkan dia minum air kosong, hari kedua saya benarkan minum milo. Sebelah malamnya dia bertanya jururawat; "Misi, bolehkah saya campur gula dalam milo saya, tawar sangatlah! ... Bagi kita bila sebut milo, maksudnya tentulah ada air, milo, gula atau susu. Tapi tak semua orang begitu.
Jadi berilah penjelasan yang sejelas-jelasnya ...... sebelum terlambat atau pecah perut kerananya !

Saturday, March 13, 2010

Air Tujuh Kolah

Gallstones (Batukarang hempedu) is a common disease. It presents with upper abdominal pain and usually the symptoms mimic that of peptic ulcer disease (sakit gastrik). Treatment of uncomplicated gallstone is easy and straight forward; remove the gallbladder. The operation is called cholecystectomy. Previously, cholecystectomy is done through an incision in the abdomen just beneath the right costal margin. Now it is done laparoscopicaly (minimal invasive surgery - keyhole surgery). It can be done as a daycase surgery, and with minimal pain.

In Kelantan, most patients describe it as pembedahan laser (which is literally wrong). Despite the advanced technique and all its advantages, many Kelantanese still prefer to go somewhere else before coming to their surgeon.

Last week I did a laparoscopic cholecystectomy on a 42-year old teacher. Ultrasound examination done two weeks earlier showed multiple gallstones. However on the day of the operation, she insisted that I repeat the ultrasound before the surgery. Her reason : She had seen a bomoh who prescribed her with "air kolah tujuh buah masjid" - drank unboiled.

Saya percaya Allah berikan ilmu kepada sesiapa saja yang dikehendakiNya, dan ilmuNya begitu luas. Saya yakin ada di sana seseorang yang Allah berikan ilmu untuk merawat sesuatu penyakit dengan cara yang berlainan. Tetapi masaalahnya, bomoh-bomoh yang kita ketahui kebanyakannya tidak jujur dengan perbuatannya. Ada seorang insan di Jelawat Kelantan yang 'menyedut' batukarang hempedu dengan pelepah betik sebelum diludahkan dari mulutya. Ada pesakit yang bawa batu itu kepada saya. Yang saya lihat hanyalah batu kerikil sungai atau yang dikutip di tepi jalan. Yang bomoh tu tak tahu ialah batu karang hempedu diperbuat dari kolesterol (hard but smooth, multifaceted and shiny) atau pigmen hempedu (black, soft and dirty). Tentunya kalau di'scan' semula masih terdapat batu yang sama walau pun telah 'disedut' keluar oleh tokmoh.

Pastinya bomoh itu tahu yang dia menipu, dia lakukan juga untuk cari makan. Malangnya orang kita mudah sangat percaya. Hujah mereka IKHTIAR. Memanglah Allah suruh kita ihktiar, tapi Dia juga beri kita otak. Dan Dia suruh kita gunakannya untuk berikhtiar.

Tok moh, tok moh ...........................

Monday, March 1, 2010


Masihkah kita ingat pelakon ini?

Allahyarham Shukery Hashim, 55 tahun, menghembuskan nafas terakhir jam 1.45 petang 10/06/2009.

(ataupun ada yang menyangka bahawa beliau masih hidup, kerana melihat drama lakonan beliau yang masih baru di kaca TV hampir setiap minggu?)

Beliau meninggal dunia 3 bulan setelah disahkan mengidap kanser pankreas.

Kanser pankreas biasanya dikesan lewat, dan pengidapnya mengalami sakit perut yang teruk (body & tail of pancreas) atau jaundis (head of pancreas). Prognosis biasanya teruk, maksudnya jangka hayat pesakit adalah pendek. My longest surviving patient after surgery (Whipple's operation) lasted only two years. Yang lainnya hidup 6 bulan ke setahun. Tanpa pembedahan, none lasted more than 6 months.
Picture: Advanced cancer pancreas with intra-peritoneal disseminations (carcinomatosis peritoneii)
Pesakit dalam gambar ini datang dengan ketumbuhan dalam perut, busung (ascites) dan disahkan mengidap kanser pankreas. Hanya biopsi yang dapat dilakukan. Beliau kembali ke rahmatulLah 4 bulan kemudian
Kajian terbaru tentang kanser ini amat mengejutkan saya:
Soft Drink Consumption Linked to Pancreatic Cancer. February 2010: Cancer Epidemiology, Biomarkers & Prevention. Kajian selama 14 tahun ini dijalankan di Singapore dikalangan penduduknya yang berbangsa China (Singapore Chinese Health Study (n = 60,524). Mereka mendapati those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15). The results of the new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not. Satu serving soft drink adalah satu tin kecil yang biasa kita beli dengan harga RM1.50
Maksudnya kebiasaan kita dan anak-anak kita yang minum minuman bergas hampir setiap hari akan mendedahkan kita kepada kanser pankreas. Ingatlah, dalam minuman itu yang ada hanya air, yang lainnya adalah kimia; pemanis, perasa, perisa, pewarna, pengawet dan penstabil (biasanya ditambah perkataan yang dibenarkan. Pernahkah kita bertanya: siapa yang benarkan?)
Oleh itu berhati-hatilah.
"Mamak, air kosong satu" - adalah satu pilihan bijak, and no longer an indication of poor financial planning !
Tepuk dada, tanya selera !!

Tuesday, February 9, 2010

Nak Fikir Dulu Doktor, Nanti Saya Telefon Kalau jadi....


A 37 year-old teacher, single - referred by a General Practitioner for a left breast lump. On examination, there was a 2X2 cm lump in the left breast. Ultrasound examination showed features suggestive of a probable cancer. Adviced biopsy.

Nak fikir dulu doktor, nanti saya telefon kalau jadi.......


Came with a much larger lump, this time with her newly-wed husband, kami baru kahwin 40 hari. On examination, the lump was 8X8 cm with areolar skin involved. Due to the rapid progression of the lesion, I told her that it was most probably a cancer. She needed proper treatment: surgery KIV chemo and radiotherapy.

OKlah doktor, buang butir saja, kalau pun kanser, kami tak mahu buang semua (mastectomy) . kami kan baru kahwin....

Excision done and the histology report came back as expected - CANCER - infiltrating ductal carcinoma. Gikgu... you need a proper cancer treatment!

Nak fikir dulu doktor, nanti saya telefon kalau jadi.......

September - December 2009: contacted patient several times. Please, you need proper treatment. Each time, the answer was :

Nak fikir dulu doktor, nanti saya telefon kalau jadi......

Today she came without an earlier appointment, AlhamdulilLah terbuka hatinya untuk mendapat rawatan!

Saya datang ni nak minta surat pengesahan doktor yang saya ada kanser untuk saya diberi pengecualian dari menghadiri kursus!

Can I see you first? Now the cancer has come back; 6X6 cm with skin and axillary nodal involvement.
Memang saya nakkan rawatan, tapi ginilah doktor:
Nak fikir dulu doktor, nanti saya telefon kalau jadi........
Inilah my well-educated patient; Nak fikir dulu, nanti saya telefon kalau jadi.........
She came with a curable 2X2 cm lesion, and the concerned surgeon is just a phone-call away, yet she chose to end her life in a miserable way.
Probably, in the future if someone says ;
Nak fikir dulu doktor, nanti saya telefon kalau jadi,
I would say;
Ikut mu lah.....

Saturday, February 6, 2010

Breast Cancer in NST

Breast Cancer: Many come when it is too late

At least 40 per cent of Malay women who came to the department were diagnosed with either third or fourth stage of breast cancer.The percentage among Chinese and Indians was lower.

In my practice, probably more than 70 percent of Kelantanese women with breast cancer presented with stage 3 or 4 disease (Locally advanced or metastatic)

Moga-moga tahun 2010 ini memberi perubahan yang positif bagi wanita Kelantan !

Monday, January 25, 2010

I lost a patient with umbilical hernia

Umbilical hernia is hardly a fatal disease. In most cases, umbilical hernia is a congenital condition. To Kelantanese, it is known as pusat bujil or uluran; and is usually seen in neonates and premature babies. Strap a 50 cent coin there or apply a 'barut perut' - settle the problem in most infants. Those who still have the hernia after the age of one year, would most probably need surgery to repair it.
This is how an umbilcal hernia looks like:

In children, the content is usually a loop of small intestine. If the umbilical hernia occurs in adult, more often than not it contains omental fat (lemak dari dalam perut).
Complications come in the form of obstruction; a loop of intestine herniates or protrudes out (into the hernial sac) and could not go back inside (into the abdominal cavity). Thus the hernia could not be reduced or pushed in. Sakitlah jadinya ! Reducible hernia is usually painless. On top of that, when the intestine gets blocked; perut jadi buncit, tak boleh makan dan muntah-muntah. It may get worse, if the blood supply to the obtructed intestinal loop is cut off by the pressure of the swollen bowel to the hernial ring. This is now called strangulated hernia. If not relieved immediately, the intestinal loop would become gangrenous (mapuh le tu!).

This is a picture of a gangrenous bowel loop in a stranguled hernia:

For many Malaysians (biasalah, selagi tak sakit, selagi itu tak buat apa-apa) they come for treatment when the hernia got obstructed. Since the last Hariraya I operated on two patients with strangulated inguinal hernia and one with strangulated umbilical hernia. The first two were operated immediately; loops of vascular-compomised intestine resected, hernioplasty done and the patients went home after few days.

The third patient came seriously ill, she came with septicemia (very ill with overwhelming infection and multiple organ failure). She was resuscitated, blood pressure stabilised and taken to the operation theatre. Her condition was made worse by her uncontrolled diabetes.

This is how her tummy looked like. This picture was taken after I had painted the abdomen with iodine solution to sterilise it for the surgery (before draping).

Once I opened the abdomen, I noted the bowel was gangrenous and feaces (tahi) all over the abdominal cavity and in the hernial sac. I had a difficult job; resecting the dead and necrotic large bowel, cleaning all the spilled-over tahi and at the same time try not to breath in too much air through my surgical mask.

Post-operatively she was pushed to the ICU and ventilated. Despite of a very aggresive management she did not recover from her septicemia and finally succumbed to her illness.
This time I did not need to put a 'sympathetic face' and say to the family ; sorry, we lost your dearest one ! Insteads, they came to me apologitically "apa nak buat, kami dah puas pujuk, suruh dia buat operation lama dulu, tapi dia yang degil"
Inilah orang kita, selagi tak nampak bayangan malaikat maut, tak mahu berubat.
Nak tidur baru nak cari bantal, nak berak baru nak korek lubang !!

Monday, January 11, 2010

Start blogging again ....... The usual Kelantanese stuff !

A 43 year old 'well-educated' gentleman presented to me last July with symptomatic anemia i.e. he complained of tiredness and breathlessness. On examination, he was pale (Hb 4.0 gm/dL), his blood pressure was normal but his heart rate was a bit faster than it should be. His lungs, heart and the abdomen were essentially normal.

On enquiry as what could be the source of his chronic blood loss, he admitted to have some bleeding piles for many years. On examination, this is what it looked like: a bleeding and prolapsed piles.

"Picture DELETED"

Piles or hemorrhoids (for treatment purposes) are classified as first, second, third or forth degree, in term of severity. First degree piles are those situated in the anal canal and they stay there. Second degree piles come out when you strain but goes back inside spontaneously when you stand up. A third degree piles needs to be pushed inside, and a forth degree could not be reduced at all.

What he need was blood transfusion to correct the anemia and a hemorrhoidectomy surgery to treat the third degree piles. He accepted the blood but refused the surgery. Fair. Many people are scared of surgical proceedures. So he was transfused with several pints of blood, given medications to treat the piles and was discharged from the hospital.

Last night, he came back(after 5 months). Again with breathlessness and severe anemia. His Hb was 4.3 gm/dL. The piles were still the same; bleeding and prolapsed. And he still refused definitive treatment. The reason is : "ada orang kata kita boleh mati ketika buat operation". I gave him a lecture on risk-management: what ever we do, there are risks involved. The important thing is how we face and manage the risks. Tak faham juga. So I told him; nanti keluar hospital jangan guna lift, kalau lift terjatuh boleh mati. Balik rumah jangan naik kereta atau motor, nanti accident, boleh mati. Jangan jalan tepi jalanraya (pedestrian), kena langgar kereta terus mati.

"Doktor, you bagi I darah cukuplah, I tak mau dengar itu semua" So he got it. But before I transfuse him with the blood, I asked him to sign the 'Blood Transfusion Consent Form'. For your information, the MOH has implemented this policy after facing few cases of medical litigation following complications of blood transfusion, mainly transfusion of HIV-infected blood.

"Masuk darah pun kena sain ke?" I told him: The chance of you dying from the blood transfusion is higher than that of dying from a hemorrhoidectomy surgery.

Itulah orang be exact....oghe kelate kito !