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Welcome

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igestive health problems are a common source of complaints when it comes to routine health and everyday well-being. While most episodes resolve themselves in a matter of days, some cases develop into major health threats that are largely preventable and usually treatable when detected earlier. This issue of devotes special attention to digestive system health. On page 4 we report on inflammatory bowel disease (IBD), a group of chronic conditions that are easy to overlook for lack of awareness and because their symptoms of abdominal pain and diarrhea don’t seem serious. IBD can impact patient quality of life while boosting the risk for potentially-deadly colorectal cancer. Regular check-ups and screenings help prevent cancer and detect it earlier. The colonoscopy is an effective tool both for diagnosing digestive conditions and for detecting pre-cancerous growths and earlystage cancer at the point when treatments are most effective and least traumatic. Our colonoscopy feature on page 10 reveals who needs one, and when to get one. Our feature on page 18 concerns liver disease, a major and growing threat in Thailand and around the world. Most cases involve chronic inflammation caused by viral hepatitis, which can go unnoticed for many years before symptoms finally appear; by that time, it may have progressed into liver cirrhosis or cancer. As always, we welcome your feedback, ideas and comments about . Please feel free to e-mail us at [email protected]. We look forward to hearing from you, and here’s wishing you better health.



C o n t e n t s 4 IBD & digestive threats

Commonplace symptoms belie more serious health threat

8 Q & A 10 Colorectal cancer screening

Do I really need a colonoscopy?

14 M.D. Focus

Get to know our doctors

16 Healthy bowels

Defining healthy bowel movements

18 Liver diseases

The digestive system depends on a healthy liver

20 Health Briefs 22 News from Bumrungrad International

Dr. Num Tanthuwanit Medical Director & Contributing Editor

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Better Health magazine is published by Bumrungrad Hospital Public Company Limited and is produced for Bumrungrad Hospital Public Company Limited by Oakins and Stone Limited, 16 Asoke Court, Suite 2-A, Sukhumvit 21 Road (Asoke), Klongtoey-nua, Wattana, Bangkok 10110. Tel: +66 (0) 2261 1211 Fax: +66 (0) 2261 1213. www.oakinsandstone.com No part of this magazine may be reproduced without the written permission of Bumrungrad Hospital Public Company Limited. 2012 by Bumrungrad Hospital Public Company Limited. All rights reserved. Publication of advertisements or sponsorships shall not constitute an endorsement by Bumrungrad Hospital Public Company Limited of the products or services promoted, of the company or organization, nor of the claims made.

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Telephone: Facsimile: Out-patient appointment: Website:

66 (0) 2667 1000 66 (0) 2667 2525 66 (0) 2667 1555 www.bumrungrad.com

IBD & DIGESTIVE THREATS

IBD: Commonplace symptoms belie more serious health threat Abdominal cramps or diarrhea don’t often point to something serious. But for millions of sufferers around the world, these routine-like symptoms turn out to be a more serious digestive disorder known as Inflammatory Bowel Disease (IBD).

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ost people shrug off the occasional bout of diarrhea or abdominal cramps. After a few unpleasant days, the symptoms will clear up on their own and life will return to normal. But not always. When symptoms clear up briefly but then return, or when they persist without relief, this may actually indicate something more serious – a chronic condition affecting millions of people worldwide known as inflammatory bowel disease, or IBD. To learn more about IBD, sought the expertise of Dr. Sinn Anuras, Bumrungrad’s Group Medical Director and a US-board certified gastroenterologist and hepatologist. Dr. Sinn has treated many IBD patients during his 30- year medical career.



Asia, but the rate of incidence across the region is lower. As a consequence of this, the general public doesn’t hear much about IBD. Doctors generally won’t have much experience diagnosing and treating IBD, and many may not have been trained to recognize the role that ethnic differences can have in causing symptom variations.” Here’s a more detailed look at the two main IBD conditions:

Crohn’s disease (CD)

Crohn’s disease is a chronic inflammatory bowel disorder affecting the gastrointestinal tract. While the GI tract extends all the way from the mouth to the anus, CD Correctly diagnosing typically affects the area from the lower IBD is quite difficult smaller intestine to the upper part thanks to Crohn’s of the colon (large disease and ulcerative intestine). The inflammation colitis producing resulting from many of the same Crohn’s disease leads to several symptoms. painful conditions, including: Dr. Sinn Anuras

“

What is IBD?



“We don’t have a specific word in Thai for inflammatory bowel disease,” says Dr. Sinn. “Several conditions that have similar symptom profiles are grouped together under a category called chronic inflammatory bowel ailments. The category doesn’t include acute bowel inflammation, a condition which is caused by a virus, bacteria or parasite and can be treated successfully with antibiotics.” The exact cause of IBD isn’t known, but it’s marked by inflammation in either or both the small intestine and the large intestine. IBD is comprised of two main disorders: Crohn’s disease (CD) and ulcerative colitis (UC). “Both conditions are more prevalent in western countries and the Middle East,” notes Dr. Sinn. “They’re both prevalent in







”

Bowel wall abscess: An abscess is a collection of liquefied tissue called pus that forms while the bowel undergoes self-repair. During this process, inflammation triggers the formation of abscesses which may cause a blockage of the intestinal tunnel;

Fistulas: Fistulas are abnormal openings or passageways that connect two organs or body cavities (e.g. bladder and vagina) that are not supposed to be connected; Intestinal inflammation: Inflammation can lead to the formation of tissue masses in areas inside the small and large intestines.



Ulcerative colitis (UC) Ulcerative colitis can be a serious, potentially-fatal disease that causes inflammation in the wall of the colon. Symptoms range from bloody defecation and high fever to fatigue and unexplained weight loss; some patients experience inflam- mation of the liver, eyes and joints. Ulcerative colitis usually responds to treatment. “Once the inflammation is brought under control, patients can live a normal life,” notes Dr. Sinn.

Diagnostic challenges

Correctly diagnosing IBD is quite difficult thanks to Crohn’s disease and ulcerative colitis producing many of the same symptoms. “It can be difficult to spot the difference between the two conditions based on symptoms alone,” Dr. Sinn explains. “In their early stages, both CD and UC cause abdominal pain and diarrhea. In severe cases, patients may have to defecate more than 10 times a day around the clock, and sometimes interrupting a good night’s sleep. Both diseases can lead to blood in stools, bouts of high fever and loss of weight resulting from the body’s inability to absorb nutrients.” Dr. Sinn describes the complex process that may be necessary to yield an accurate diagnosis: “A patient’s condition is termed chronic when symptoms continue for more than two weeks and prove unresponsive to medication. Laboratory stool testing may be used to detect the presence of an infection or inflammation. If no infection is found, a colonoscopy and a CT scan may be needed to determine the patient’s condition and the location of the affected area. Laboratory testing of tissue samples from the patient’s intestines may be needed to confirm the diagnosis and determine the specific disease type.” Living with IBD means dealing with daily challenges that can greatly affect a patient’s quality of life, especially considering the frequent need to defecate and the resulting loss of blood and important nutrients. It can certainly affect a patient’s quality of life with complications including anemia. In the case of both CD and UC, when chronic inflammation goes undiagnosed and untreated, patients are at a higher risk for developing colorectal cancer.

Crohn’s Disease

Normal Colon

Ulcerative Colitis

Ulcerative Colitis

Treatments for IBD Medication is the primary first-line treatment for the two IBD conditions. “After confirming the diagnosis, a doctor will usually prescribe anti-inflammatory medication,” Dr. Sinn explains. “As the inflammation subsides, symptoms

Get to know the symptoms of IBD C



rohn’s disease and ulcerative colitis share these commonplace symptoms: Abdominal cramps that cause pain when pressure is applied; Diarrhea occurring multiple times per day; Bloody stools; Unexplained weight loss; Constantly feeling tired or fatigued.



will dissipate and the illness enters a state of remission. Patients will need to be examined by their doctor at regular intervals. Patient compliance – especially adhering to instructions for taking medication – is the best way to prevent a recurrence of IBD, just as it is for managing other chronic conditions.”

Diagnosing IBD can be difficult. “ It requires trained and experienced doctors to recognize the role that ethnic differences can have in causing symptom variations.

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Not all patients are good candidates for medication – notably those with other, co-existing health problems. For these patients, and for those who haven’t responded to treatment with medication, surgery may be the next best option. “Surgery may be recommended for treating ulcerative colitis, since the disease is confined within the colon,” Dr. Sinn explains. “But Crohn’s disease affects both intestines; surgery is generally not recommended except where connective tissues have narrowed a patient’s bowel tunnels, which makes it harder for food to pass through the narrower lumen.”

Dedicated IBD Clinic

Specialized knowledge and training are all the more important in light of IBD’s nondescript symptom profile and variability related to patient ethnicity and disease genotype. “More attention is being paid to IBD in Thailand in recent years,” notes Dr. Sinn. “At Bumrungrad, we’ve



treated more than 300 new cases of IBD patients, including Thais and patients coming from Asia, Europe, North America and the Middle East. We reached a point where our significant expertise and the growing volume of patients justified having a dedicated IBD Clinic. Patients certainly appreciate the greater convenience, and it has helped raise awareness about IBD. “Our medical team has extensive IBD training and experience using advanced procedures and technologies, so patients know they’ll enjoy an international standard of care. The specialty clinic is also an important source for

data that can be studied and added to the knowledge base among medical professionals in Thailand and overseas.” While IBD and other chronic diseases can last a lifetime, patients don’t have to give up their hope of enjoying a good quality of life. If you know IBD’s symptoms and take appropriate action when faced with those symptoms, you will be in a much better position to bring the condition under control.

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IBD or IBS?

t’s easy to confuse inflammatory bowel disease (IBD) with irritable bowel syndrome (IBS). Beyond their similar names and initials, they produce many of the same symptoms – especially abdominal cramping and frequent diarrhea. But the two are separate, unrelated conditions; IBS affects more people but is much less serious. IBD causes inflammation, but IBS does not.

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Q & A

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early everyone has an occasional gastro- intestinal problem. In this edition of Q&A, Dr. Sinn Anuras, a US-board certified gastroenterologist and hepatologist, answers readers’ GI-related health questions.

Q: I’ve heard that aspirin helps prevent colorectal cancer. Is that really true?

Q: I have been burping a lot more

frequently than before, and it’s quite embar- rassing. Is there an easy way to fix this?

A:

A number of factors can cause air and gas to accumulate in the GI tract. Swallowing food or drinking water permits air to flow into the stomach – even more when chewing gum or sucking on a hard candy. Foods that can’t be digested completely – carbohydrates, high-fiber foods, milk, bread, corn, sugar, broccoli, cabbage, potatoes and beans, etc. – tend to produce gas. Certain types of bacteria produce gas inside the colon while food is being digested. The average person releases gas about 15 times a day through burping and farting. If you’re experiencing an above-average frequency, you may get some relief by adjusting your food habits in accordance with these guidelines: Take note of which foods appear to be causing gas, and consider reducing or avoiding them altogether; Eat at a slow pace and chew your food thoroughly; Drink still water instead of carbonated drinks; Avoid candy and gum. If changing habits doesn’t help, or if your stomach pain persists even after gas is released, it’s best to consult your doctor.

A:

Aspirin is a powerful medicine. Many doctors put their patients on aspirin regimens, usually to boost prevention of cardiovascular disease and stroke. Aspirin can also cause some potentially-serious side effects, so it should only be taken on a regular basis with a doctor’s supervision. You may have read about a research study which found that patients on a daily low-dose aspirin regimen for five years enjoyed a 40 percent decline in their risk for colorectal cancer – a significant drop. But further studies are needed to re-confirm the initial findings and to determine the optimal dosage levels. Aspirin’s potential side effects shouldn’t be taken lightly; aspirin can harm patients being treated for bleeding in the stomach or the brain. The body is complex, and medicine doesn’t always produce the same effect on each patient. Check with your doctor before starting any new medication regimen, and always adhere to the instructions when taking any medication.

Q:

Café latte is my favorite drink. But I seem to get diarrhea every time after I’ve had a cup. Is this a type of milk allergy? Is there something that can help?

A: Diarrhea can be caused by many factors.

Your situation appears to be a case of lactose intolerance. [Lactose is the sugar contained in milk.] It’s common in adults and results from the normal decline in lactase, an enzyme that digests the sugar in milk. Lactase pro- duction peaks when we are babies and then begins to decline gradually over time. Lactose intolerance and a milk allergy are two different things. While lactose intolerance causes diarrhea, an allergy to milk is a reaction to milk proteins. Milk allergies can cause rashes, swelling of the eyes and asthma, but usually do not cause diarrhea. If you experience stomach pain or diarrhea within two hours after drinking milk, try avoiding milk for a while to see if your condition improves. If it does improve, then you are lactose intolerant. You can resume milk consumption grad- ually, and note the volume you’re able to handle while remaining symptom-free. Doctors may prescribe enzyme supplements to alleviate lactose intolerance. If your condition persists, your doctor may need to do further testing to diagnose what’s causing your symptoms.

Have a question? You can submit your question for possible inclusion in future issues of , by e-mail [email protected] or by mail to Editor, Magazine, Bumrungrad International Hospital, 33 Sukhumvit 3, Wattana, Bangkok 10110, Thailand.



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COLORECTAL CANCER SCREENING

Do I really need a colonoscopy? This high-tech outpatient procedure plays an important role in the prevention and earlier detection of colorectal cancer, which can be treated more successfully, and with less patient trauma, the earlier it’s detected.

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olorectal cancer is a serious, potentially-fatal disease. It’s also preventable, treatable and curable the sat down with earlier it’s detected. Dr. Poungpen Sirisuwannatash, a specialist in gastro- enterology and hepatology at Bumrungrad, to find out more about the colonoscopy procedure and its use in screening for colorectal cancer, and who should have one.

: Is colorectal cancer a significant health threat in Thailand? Dr. Poungpen: Colorectal cancer is now the fourth most

common cancer among Thais. Among men, it ranks third among all cancers, and for Thai women it ranks fifth. And the number of cases continues to trend up.

: How can a person know if he or she has

a high risk of, or may already have, colorectal cancer? Dr. Poungpen: Most patients don’t know that they

already have the disease. It’s usually detected in one of three ways: In a small percentage of cases, it’s detected when a health-conscious patient has a periodic check-up including colorectal cancer screening. The second way involves patients who consult their doctor only after noticing something suspicious that gives them cause for concern. Some patients in this group turn

Prevent colorectal cancer now!

out to have only polyps or non-cancerous tumors, both of which can be treated successfully. The third way involves patients seeing a doctor only after they notice serious symptoms such as bloody stool. Quite a few of these patients will be diagnosed with colorectal cancer that has already progressed beyond the early stage.

: What should people look for in terms of

warning signs? Dr. Poungpen: Colorectal cancer can be prevented, largely

because the pre-cancerous stage tends to last quite a while, and tests are capable of detecting it during this pre-cancer stage. But symptoms can prove difficult to recognize, and some patients remain symptom-free during the earlier stages. Commonplace symptoms such as diarrhea, constipation and flatulence are easy to mistake for minor gastro- intestinal disorders. Some people assume bloody defecation indicates hemorrhoids. Many patients figure it’s not something worth the inconvenience of a doctor visit. I encourage people to broaden their thinking about when to talk to their doctors. Beyond seeing your doctor when you need treatment for a disease or condition, doctors can be of great help in disease prevention. Periodic check-ups are critical for detecting small problems well before they grow into much more serious threats. People in good overall health and with no family history of cancer should generally undergo colonoscopy cancer screening by age 50.

: What procedures other than a colonoscopy

can be used to detect colorectal cancer? Dr. Poungpen: There are other tests available – primarily

Dr. Poungpen Sirisuwannatash

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laboratory stool examination and barium enema testing – but these tend to be less accurate than a colonoscopy. Patients who want a less-invasive procedure may prefer a virtual colonoscopy for its more detailed results compared to a traditional barium enema X-ray. The virtual colonoscopy procedure is capable of detecting between 60 and 90 percent of polyps larger than 0.6 cm. If polyps are detected during a virtual colonoscopy, a total colonoscopy is usually necessary so that a biopsy can be performed. When screening reveals significant symptoms pointing to cancer, doctors will usually schedule a total colonoscopy prior to deciding on a precise treatment strategy. It’s worth noting that colonoscopy screening for colorectal cancer is widely accepted by the global medical community as being an effective tool for cancer prevention – and a total colonoscopy is the gold standard.

Colonoscopies can spot abnormal tissue growths that may lead to future problems such as inflammation or polyps. Sometimes it takes finding a polyp to get a patient to fully recognize the importance of screening tests.

chemotherapy and radiation therapy. Treatment costs are exponentially higher than having a colonoscopy – and much more disruptive to a patient's quality of life. Prevention and risk reduction are investments that pay

: What happens if the colonoscopy detects a problem? Dr. Poungpen: If polyps or pre-

worth noting “ It’s that colonoscopy

cancerous tumors are present in the colon, they can usually be removed right away. The patient would be reclassified as being in the higher-risk group to be monitored periodically. If no problems are found, it’s safe to say the patient will remain free of colorectal cancer well into the future for at least five to ten years. Studies show that screening reduces colorectal cancer incidence and death rates by 23 to 31 percent, a significant reduction.

: What limitations or



screening for colorectal cancer is an effective tool for cancer prevention.”



Dr. Poungpen Sirisuwannatash

other concerns should patients know about? Dr. Poungpen: One thing to note is that a colonoscopy isn’t exactly cheap, and it costs more than stool testing or X-rays. But the cost pales in comparison to the cost of cancer treatment, which may involve surgery,

Common Colon Disorders

huge dividends that can be enjoyed for many years. A colonoscopy is not a routine procedure that any doctor can perform. Physicians must undergo extensive training and skills development before conducting their first colonoscopy. As with all medical treatments and procedures, there are risks and possible side effects that patients should know about: anesthesia-related effects, obstructive sleep apnea, bleeding in the bowel or perforation of the bowel have occurred in only a very small number of cases in experienced hands.

: Overall, should patients be concerned about the safety of a colonoscopy? Dr. Poungpen: Thousands of colonoscopies

Ulcerative Colitis

Diverticulosis (Sacs in the inner lining of the colon)

Colon Polyps

Diverticulitis (Inflammation of the sacs in the inner colon lining)

A colonoscopy is an opportunity for doctors to conduct a thorough examination of the colon, to identify the presence of possible abnormalities, and to help diagnose the nature and cause of any underlying colon conditions.

are performed every day without incident. Side effects and complications are rare. For example, bowel perforation occurs only once in every 3,000 to 5,000 colonoscopies. Doctors will explain the risks, possible complications and potential side effects with patients beforehand. People taking thrombolytic medications will usually be instructed to stop taking them for about a week. An anesthetist may be present to monitor overweight patients, people with obstructive sleep apnea and short-necked or cardiovascular-compromised patients. No one should have to go through the trauma of battling colorectal cancer. The disease is largely preventable and usually responds well to treatment when detected earlier. I urge people not to skip their colonoscopy screening; it’s a procedure that offers tremendous protection against a serious health threat.

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M.D. FOCUS

Get to know our doctors Meet four Bumrungrad physicians as they share their thoughts on a range of health care topics.

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roviding the highest standards of patient care requires a hospital-wide commitment and professional expertise. Bumrungrad’s medical staff includes over 900 world class doctors of the highest caliber, with outstanding professional credentials and advanced training across the full spectrum of medical sub-specialties.

Dr. Boonsri Chanrachakul

Obstetrician and Gynecologist

Dr. Boonsri graduated from Chulalongkorn University’s Faculty of Medicine, and then received his doctoral degree in Obstetrics & Gynecology from Nottingham University. He earned diplomate certifications from both the Thai Board of Obstetrics & Gynecology and the Thai Sub-board of Maternal & Fetal Medicine. Throughout his medical career he has been helping numerous patients through difficult pregnancies.

Q: What do you find

most challenging about being an obstetrician?

A: Pregnancy complications

can be sudden and unpredictable. It’s certainly challenging when many things are beyond our control and difficult to prevent. Many patients who have complications were in excellent health. Gynecologists must carefully check every detail and be ready all the times in order to deal with unexpected events. We should also offer patients and their spouses clear explanations to make them understand the situation.

Dr. Non Wajanaponsan

Q: What principles help guide you in your work? A: I believe that education and the dissemination of

knowledge are critical to successful teamwork. There is no way I can properly take care of patients on my own. Every team member – doctors, nurses and support staff – needs to work effectively and seamlessly with the rest of the team to ensure patients receive the best possible care. I share everything I know with the team because everything runs more smoothly when each of us knows how we fit into the team. It’s also important that we provide patients with sufficient knowledge about what to do in emergency situations.

Critical Care Physician (ICU)

After graduating with First Class honors from Siriraj Hospital’s Faculty of Medicine, Dr. Non was awarded a fellowship for advanced studies at a leading institute in the US city of Pittsburgh. He chose to focus on critical care medicine, a specialty requiring a wide range of medical knowledge.

Q: What are the main duties of a critical care physician? A: My job is to take care of patients across a wide range

of life-threating conditions – respiratory failure, low blood pressure, multiple organ failure, and others – that require an intense level of care. I have to manage multiple systems of the body which have implications for a patient’s survival.

Q: What aspect of your work poses the greatest challenge? A: In my specialty, our body and mind must be ready and prepared to handle the stresses of treating patients in life-threatening situations. When a patient passes

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away, you can’t help but feel sad. However, as doctors, we must keep our emotions in check so we can help other patients.

Q: Is there one lesson you’ve learned that helps you in your work? A: During those moments when I’m feeling stressed or tired, I think about something my mentor used to say: “You have the best job in the world, because in no other job can you help save the lives of so many people.” That rings true to me because, when we can save a patient facing near-certain death, it’s a wonderful feeling.

Dr. Vitchaphan Hemrungrojn

Otolaryngologist

After graduating from Mahidol University’s Faculty of Medicine at Ramathibodi Hospital, Dr. Vitchaphan went on to earn a Diploma from the Thai Board of Otolaryngology. He did his advanced studies in the US, focusing on endoscopic sinus, head and neck surgery. At Bumrungrad, his vast experience and expertise are helping patients succeed in the battle against cancer.

Q: What’s the most challenging part of your work as a doctor? A: After treating so

many cancer patients over many years, I’ve come to recognize that cancer places a tremendous burden on a patient’s mental and emotional wellbeing, and it affects me as well. It’s more apparent in the more serious cases, such as when an organ must be removed which will impact a patient’s life quality, or a cure is simply not possible. Doctors need advanced communication skills with patients, especially when they have to give difficult news. Doctors need to have a calming manner and be able to explain a situation to each patient in a manner that’s right for that particular patient.

Dr. Kessarin Panichpisal

Q: Are there particular cases or certain patients who always stay with you? A: One patient I think about often came to me suffering from sinus cancer. His cancer had grown so much. But the man was desperate for help – he still needed to stabilize his business, and he had very young children who still needed their father to take care of them. If a cure wasn’t possible, could I at least help him stay alive for two more years so he could put everything in order? We focused on supportive therapy to preserve as much life quality as possible. We explored every method and idea – conventional and otherwise – and somehow, he held on for those two years and passed away with no regrets. This confirmed my belief that, if we’re willing to give our best possible effort, even when the odds are against us, we can always find some way to help when a patient needs it most.

Neurologist

After graduating from Chiang Mai University’s Faculty of Medicine with First Class honors, Dr. Kessarin earned her diplomate certification from the American Board of Internal Medicine and Neurology. She did advanced studies in vascular neurology at the State University of New York (SUNY) and was hired as a professor at SUNY Downstate Medical Center in New York before returning home to join Bumrungrad.

Q: What got you interested in neurology? A: Anatomy has always been my favorite subject,

especially neurology which is extremely complex and very challenging. I call on what I’ve learned when evaluating a patient’s condition, particularly with acute stroke patients, many of whom arrive at the hospital with paralysis and have lost their speech function. Prompt diagnosis and swift decision-making are vital to helping these patients. I think I’m at my best during these tense, high-pressure situations.

Q: Which technologies are helping stroke victims

the most?

A: There are many recent technologies that have

improved stroke treatment when anticoagulants aren’t successful. We can use an angiography to locate the blood clot and use it to directly apply the anticoagulant. Or we can insert a stent to re-open the

artery and remove the clot. The advances in these types of procedures allow us to save much more healthy brain tissue than ever before.

Q: What attracted you to Bumrungrad? A: The system of patient care at Bumrungrad follows stringent international standards, and the medical team includes many recognized experts across all areas of medicine – there are neurologists who are leading experts in stroke treatment, specialists in multiple sclerosis, epilepsy, dementia, and more. Patients have access to a wide range of experts.

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HEALTHY BOWELS

What bowel movements tell us about health Our digestive “waste” has a lot to say about our health and well-being.

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ou may be flushing away some valuable insight into your health. Though it’s an abundant source for feces- related humor, digestive system waste also provides useful health information. Variations in color, shape, size and fecal texture can signal the presence of certain health conditions and nutritional imbalances.

As a general rule-of-thumb, the desired waste indicating good digestive health is dark brown in color and smooth in texture (though certain foods may cause changes in bowel movement color, texture or consistency without affecting one’s health). The following guidelines explain the health implications of various characteristics of digestive waste.

Small, separated lumps, hard (pebble-like) texture and difficult to pass.

Stools are cylindrical in shape (resembling sausage) and texture is smooth and soft.

Constipation is indicated by hard, dry stools, likely due to insufficient intake of fiber and water.

This is the gold standard for stools and an indicator of good eating habits and a general state of wellness.



Good stool news is meant to be shared, so tell your family and friends about your healthy dietary habits and encourage them to make positive changes.

Cut back on eating protein-rich foods like meat and dairy products. Drink more water (at least 8 cups a day) and boost dietary fiber by eating more fruit, leafy vegetables and brown rice.

Sausage-like shape but texture is hard and lumpy. Indicates constipation resulting from too little consumption of fiber and water.

Avoid eating too much protein from meat and dairy products. Increase drinking water and fiber in diet, add more leafy vegetables, brown rice and fruit.

Soft, round blobs with smooth edges. Waste is easy to pass.

Indicates something is causing food to pass through the colon too quickly. This may cause dehydration and reduce nutrient absorption.

Be sure to include plenty of fruits and vegetables in your diet and consider adding yogurt to help balance intestinal bacteria.

Cylindrical in shape with cracks on the outer surface.

Mushy, loose and fluffy in texture and with uneven edges, easy to pass.

Surface cracks and dryness indicate insuf- ficient intake of water and other fluids.



May signify an allergy to certain foods or may be due to a bacterial imbalance in the colon, leading to dehydration and malnutrition.



Consider a short-term change in the types of fiber-rich foods consumed. Reduce fruits, fruit juice and leafy vege- tables while increasing consumption of whole-grain foods. Include yogurt to help restore intestinal bacteria balance.

Increase water and fluid intake.

Color matters ! * Normal

Indicates possibility of bleeding coming from the lower gastrointestinal tract (colon and rectum). Some cases may simply be the result of eating large volumes of red- colored foods such as watermelon or beets.

Indicates healthy intake of leafy green vegetables. May indicate problems related to the pancreas, gallbladder or other biliary system condition. Can also result from taking medication to block the absorption of fat. Indication of bleeding from the upper gastrointestinal tract or over-consumption of iron. A number of factors can affect stool color. The above guide is



intended for information purposes only and is not intended for use in medical diagnosis. If you detect a change in bowel movement habits, you should consult a healthcare professional for further investigation.

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Watery, liquid consistency throughout. No solid pieces. You may have a GI infection or other digestive problem that should be examined by your doctor.



A doctor’s visit is necessary. Follow your doctor’s advice, which may include recommendations for eating freshly-cooked foods that are easily digested (e.g. brown rice soup, vegetable soup). Drink plenty of water and fluids containing electrolytes to prevent dehydration.

For healthier bowel movements . . . Reduce stress, anxiety and worry; Exercise regularly and get sufficient rest; Don’t push too hard during a bowel movement, as this squeezes the sphincter muscle and can make constipation worse.

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LIVER DISEASES

Digestive system depends on a healthy liver Cancer and other diseases of the liver represent dangerous threats to health. Many develop gradually without any noticeable symptoms; by the time symptoms appear, the disease may have reached a life-threatening stage.

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ometimes, numbers speak volumes: Liver cancer accounts for one in four cancer deaths in Thailand, more than any other cancer. The most recent statistics from Thailand’s Ministry of Public Health revealed that liver cancer killed more than 14,000 Thais in 2010 alone. The number of new cases continues to grow; on a typical day, 30 patients in Thailand will be diagnosed with liver cancer. The liver’s importance is hard to overstate. “The liver is the body’s largest internal organ, and it’s involved in many important body functions,” says Dr. Nusont Kladchareon, a UK-board certified gastroenterologist and hepatologist at Bumrungrad. “The liver synthesizes many important proteins and other essential substances including blood- clotting helpers. It also produces certain hormones and digestive juice or bile.” The liver converts and stores nutrients, vitamins and minerals, and it breaks down foreign chemicals and toxins from the body through the waste removal process. “It’s also the only organ capable of repairing itself by generating new cells to replace damaged cells,” Dr. Nusont notes. “If it becomes impaired by disease, the liver’s function may decline to the point where a patient’s life is in danger.” Cancer is far from being the only threat to a healthy liver; a number of liver diseases are growing in prevalence due to unhealthy lifestyle choices, namely heavy alcohol consumption, unsafe sex and sedentary living. The most serious liver threats include:

Hepatitis Hepatitis is the general term describing inflammation of the liver and has several possible causes, including; Hepatitis viruses A, B and C: Viral hepatitis is a major public health problem in Thailand, where hepatitis A and B are common while hepatitis C is relatively rare. The hepatitis A virus is transmitted through contaminated foods and beverages while hepatitis B and C are transmitted through contact (including sexual contact) with infected blood or body fluids. Hepatitis B and C can also be spread through razor sharing and during cosmetic procedures such as tattooing, body piercing, and even manicures and pedicures. “People need to be aware of their personal risk factors,” cautions Dr. Nusont. “Risky behaviors, such as having multiple sex partners or sharing personal care items like razors and tweezers, promote the spread of such viral infections. Mothers carrying the hepatitis B virus may pass the infection to their babies during childbirth. Some newborns fight off the infection and develop lifetime immunity; babies who can’t clear the virus become hepatitis B carriers and may eventually suffer chronic hepatitis, putting them at a greater risk for liver cirrhosis and liver cancer.” Fatty Liver: Fatty liver disease, the abnormal accumulation of fat in the liver, is another leading cause of liver disease. “Inflammation can be related to fatty liver and can damage liver cells,” says Dr. Nusont. “Without

Common causes of liver diseases

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proper care and treatment, the condition can become chronic and, in some cases, may progress to liver cirrhosis or life-threatening liver cancer later in life.” While the precise cause of fatty liver disease is not fully understood, evidence has linked excessive alcohol consumption to fatty liver, which eventually leads to liver inflammation. Abstaining from alcohol doesn’t fully protect against fatty liver; Non-alcoholic fatty liver disease (NAFLD) tends to strike people who have diabetes, are overweight and/or have high cholesterol. Alcohol abuse: Long-time heavy drinkers face a high risk for developing alcoholic hepatitis. Drinkers already diagnosed with fatty liver disease, hepatitis B or hepatitis C may compound the damage to their liver if they continue abusing alcohol. Dr. Nusont Kladchareon Doing so makes it easier for the condition to progress to cirrhosis and, eventually, to liver cancer. “The leading causes of hepatitis can vary significantly from one community or group to another,” says Dr. Nusont. “In Thailand, alcoholic hepatitis and viral hepatitis are highly prevalent. Viral hepatitis and hepatitis related to fatty liver disease are very prevalent in urban communities and among more affluent groups. “What’s most concerning about these liver disorders is their lack of early warning signs,” notes Dr. Nusont. “During the early stages of chronic liver inflammation and fatty liver disease, most patients have no obvious symptoms – or symptoms are so subtle that patients simply dismiss them as insignificant. Most people are totally unaware they have a liver disease until it has progressed significantly to the point where symptoms are too obvious to ignore – for example, when jaundice turns their skin and the whites of their eyes to a yellowish tint.”

Liver cirrhosis

During the early stages of liver disease, most of the liver’s tissues remain healthy, and the liver continues functioning normally. As the disease progresses further without treatment, healthy tissues begin to undergo slow but progressive scarring, known as fibrosis. Slowly but surely, scarring affects more liver tissues, and liver function begins to decline. “Damage from liver fibrosis eventually affects enough liver tissue to impair the liver’s capacity to heal itself,” Dr. Nusont explains. “At this point, treatment can only slow the rate of further damage and reduce the severity of symptoms. Patients with liver cirrhosis will require close monitoring as they’re at greater risk for liver cancer. Earlier cancer detection improves the effectiveness of treatments. In cases of severe liver cirrhosis, liver transplantation may be the only effective treatment option.”

A message from your liver

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s your liver, I will do my utmost to withstand all of the challenges and threats I face without protest. Whenever you hear something coming from me, don't ignore it. Take it seriously, because we may not have much time left."

Liver cancer The liver is susceptible to both primary and secondary (or metastatic) liver cancer. Primary liver cancer originates in the liver, usually as a result of chronic hepatitis and cirrhosis. Secondary liver cancer refers to cases where cancer originates in another organ – the colon, stomach or pancreas, for example – and eventually spreads to the liver. “Years ago, liver cancer was difficult to treat successfully,” recalls Dr. Nusont. “Sadly, most liver cancer patients didn’t survive very long in those days. With recent and rapid medical advances, liver cancer is now much more treatable at every stage. Survival rates have improved greatly; many more patients experience a remission or even a cure of their cancer.” Healthy lifestyle choices are critical to preventing liver diseases and to limiting their severity. Despite all that we know, too many people turn feeling fine today into skipping their next health check-up or putting off those plans to start exercising or eat healthier. “Where the liver is concerned, we can’t simply wait for symptoms to give us fair warning,” says Dr. Nusont. “A lot of liver tissue can be saved by earlier intervention. See your doctor on a regular basis, get vaccinated, and lower your risk factors. That’s a mantra that delivers great protection from life-threatening liver diseases.”

Protect your liver starting today

Limit alcohol consumption. The safest amount of alcohol is none at all; Practice safer sex; Avoid sharing personal items (e.g. razors, nail clippers, tooth brushes). Keep ‘personal’ items to yourself; Know your hepatitis immunity status, have it checked and/or get vaccinated; Check with your healthcare professional before starting any new herbal or dietary supplement regimens; Wear a mask and gloves to protect yourself from exposure to chemicals; Follow your doctor’s recommendation for periodic check-ups and health screenings.

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HEALTH BRIEFS

Childhood obesity raises risk for liver cancer in adults Obese kids appear to be at greater risk for developing liver cancer later in life. That’s according to the results of a recently published study that tracked more than 320,000 Danish adults. The study showed that each one-point increase in a child’s body mass index (BMI) corresponded to a 12 percent increase in the risk for developing hepatocellular carcinoma, one of the more common types of liver cancer. Obesity is a known risk factor for a number of serious health problems and metabolic disorders, including heart disease, type-2 diabetes and fatty liver disease. The study further reinforces the importance of teaching kids about healthy lifestyle habits, including exercise and nutrition, as early as possible.

Caution advised over supplements that may cause liver damage Some supplements are better than others. And based on the preliminary results of a research study, consumers taking weight-loss or body-building supplements should be especially careful to guard against liver damage. For the study, researchers in the US evaluated patients from a national database of consumers who had filed reports claiming they suffered liver damage after taking health supplements. Patients answered questions regarding their supplement history and were given a number of liver-related tests. The results linked specific types of sup- plements to different types of liver injury; supplements promoting body-building had the highest rate of damage – about half who took them suffered liver damage, with the most common symptoms including jaundice that, in some cases, was so severe it required hospitalization. Researchers found weight-loss supplements to be a direct cause of liver damage in about 40 percent of patients who took them; more than 10 percent eventually needed a liver transplant. It’s important to talk to your doctor if you’re considering taking supplements, as many are not regulated.

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Alcohol may boost risk of breast and liver cancers A new study points to a higher risk for some cancers, including breast cancer among women, liver cancer, and some cancers of the gastro-intestinal tract. Results of the study were published in a recent issue of the journal Alcoholism: Clinical & Experimental Research. The study identified a link between the way the body meta- bolizes alcohol and damage to DNA that raises a person’s risk for certain types of cancer. Older studies dating back to the 1980s identified a relationship between alcohol consumption and some cancers (mainly breast, colon and liver cancer) though these studies did not establish that alcohol was actually causing the cancers. People of East Asian ethnicity appear to be at higher risk of cancer due to alcohol. An estimated 30 percent of East Asians aren’t able to convert alcohol to acetate due to a genetic variation. That difference is behind their much higher risk for developing esophageal cancer due to consumption of alcohol. The study exposed human cells to alcohol concentrations equi- valent to levels found in the body during social drinking. The cells were engineered to metabolize alcohol into acetaldehyde by an enzyme found in human liver and breast tissue. The study may spur a new round of research to examine the precise causal nature of the way the human body metabolizes alcohol. In the meantime, moderation continues to be the healthiest approach to drinking.

CAUTION !

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NEWS FROM BUMRUNGRAD INTERNATIONAL

New IBD Clinic opens at Bumrungrad

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umrungrad has opened a new specialty clinic to serve the growing number of patients with chronic inflammatory bowel disease. At the new IBD Clinic, patients are cared for by a team of experienced, internationally-trained doctors and medical support staff, using an array of advanced equipment. The clinic features a dedicated, stateof-the-art laboratory facility designed to enhance patient convenience and care.

Pictured (from left): Television personality Pawarisa Phenchati; Mr. Mack Banner, Hospital CEO; Dr. Sinn Anuras, Group Medical Director; Dr. Rujapong Sukhabote, Director of Bumrungrad’s Digestive Diseases Center and the IBD Clinic; Dr. Num Tanthuwanit, Medical Director; and Dr. Vibhakorn Permpoon, gastroenterologist specializing in IBD.

Health campaign takes aim at cervical cancer

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n celebration of Her Majesty the Queen’s birthday anni-

versary, Bumrungrad launched a campaign to raise public awareness about the dangers of cervical cancer and how women can protect against the disease. Launched in conjunction with the Thai Gynecologic Cancer Society, the “Fight Cervical Cancer” campaign focuses on the preventive steps women can take to protect against one of the leading killers of Thai women.

Volunteers boost Thum Dee Phue Phor re-forestation

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ore than 250 volunteers, including Mr. Chai Sophonpanich (pictured below, third from left), Chairperson of the Board of Directors, other Bumrungrad executives and staff members together with volunteers from Bangkok Insurance Public Co., Ltd. and Bangkok Life Assurance Public Co., Ltd., travelled to Petchaburi province in support of Thum Dee Phue Phor (“good deeds for the King”), an initiative to help re-forestation efforts in the province’s Huai Sai area. During the visit, Bumrungrad doctors and support staff set up a clinic at the Huai Sai Royal Development Study Center to provide no-cost treatment and medication for needy residents without access to regular medical care. The Thum Dee Phue Phor event was part of the Ruam Rang Ruam Jai Bhappy 3 (“BHappy Working Together”) charity program.

Pictured (left to right): Dr. Jitra Anuras, Senior-Associate Medical Director; Dr. Wisit Supakarapongkul, Director of the Women’s Center at Bumrungrad and Chairperson of the Thai Gynecologic Cancer Society; Dr. Num Tanthuwanit, Medical Director; Mr. Mack Banner, Hospital CEO; Dr. Visith Dusitnanond, Associate Medical Director; and Dr. Thanakrit Chintavorn, Coordination Physician.

Giving the gift that’s truly heartfelt

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umrungrad’s Rak Jai Thai program is in its fifth year of providing no-cost heart surgeries for needy Thai children and adults suffering from congenital heart defects and valvular heart disease. From the program’s 2008 inception through September 2012, over 600 patients have received surgical treatment. Donations from the public are welcomed and appreciated. Donations are accepted through the following channels: • Online at www.bumrungrad.com/onlinedonation ; or

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• Via bank transfer to the Bumrungrad Hospital Foundation (Bangkok Bank savings account # 197-0-111157, North Nana branch). Please submit a copy of your transfer confirmation receipt to Bumrungrad’s accounting department (located on the hospital’s 4th floor), or you may fax a copy to 0 2667 2031.

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