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 !