Dear Editor, Alpha-fetoprotein (AFP) is the most established biomarker for surveillance of hepatocellular carcinoma (HCC) in at-risk individuals. However, its sensitivity and specificity are not very satisfactory.1 Protein induced by vitamin K absence or antagonist-II (PIVKA-II) is a newer biomarker for HCC but without a widely established cut-off.2,3 Recent...

Dear Editor, The Academy of Medicine, Singapore (AMS) guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting and an accompanying editorial were published in the January 2022 issue of the Annals.1,2 An evidence-based approach was used with reference made to relevant published literature. The...

Dear Editor, I refer to the editorial “Ensuring safe sedation during gastroendoscopy”1 and the original article “Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during endoscopy in the hospital setting”2  in your journal in January 2022. The American Society of Gastrointestinal Endoscopy (ASGE) and the European...

Dear Editor, Propofol is a potent intravenous sedative-hypnotic agent. Its popularity for sedation has increased in the last 3 decades because of its smooth, rapid onset of action and fast post-procedural recovery.1 Nonetheless, propofol depresses cardiorespiratory function and could result in life-threatening adverse effects. A workgroup, mainly consisting of gastroenterologists and...

Dear Editor, We read with interest the paper by Ang et al.1 on Singapore guidelines in the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. We are especially intrigued by Statement 6, stating that propofol sedation for endoscopy can be safely and effectively administered by trained...

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for their analgesic or anti-inflammatory properties in musculoskeletal pain. However, they are not without adverse effects, such as abdominal pain, diarrhoea, nausea and fluid retention, which are reported to occur in 30% of people taking NSAIDs. This article is available only as a...

The current disease pattern in Singapore (an island state of 3.3 million people composed of 76% Chinese, 14% Malays, 7% Asian Indians and 3% Others) is dominated by non-communicable diseases. There have been increasing trends, though with recent declines, for coronary heart disease (CHD) and cerebrovascular disease. This article is...

The last two decades have witnessed dramatic changes in the understanding of gastric cancer: a rapid decline in global incidence, its association with Helicobacter pylori gastritis, and the new information regarding its molecular biology. Nevertheless, gastric cancer remains the second commonest cancer in the world in terms of morbidity...

Faecal incontinence is the inability to control the passage of gas, liquid or solid through the anus. Its severity varies from infrequent passage of gas to persistent lack of control of solid stools. This article is available only as a PDF. Please click on “Download PDF” on top to view...

Direct cholangiopancreatography has long been considered the standard of reference for assessment of the biliary tree and is generally safe, reliable and widely available. However, these methods are operator dependant and have the potential for morbidity in some patients (3% to 5%) with complications such as acute cholangitis, pancreatitis,...

Although standard oesophageal manometry has been widely used in the West for many years, normal manometric values that have been well described for healthy volunteers in the West may not be applicable to this part of the world. Such normal values vary between investigators, even within the same study...

Colour image analysers have been extensively used in medical research since 1970 for histomorphometric studies. Image analysis gives more information and a better understanding of relative morphological changes in histological tissue sections. This is especially pertinent when different morphological areas are immunohistologically stained and present in contrasting colours or...

The understanding of blood supply is the cornerstone of successful tissue transfer in reconstructive surgery. This understanding has been derived largely from cadaveric dissections, combined with injections to outline the blood supply. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Metastatic spread is the principal reason of treatment failure in solid tumours. Surgery, radiation therapy and chemotherapy have not manifestly altered the prognosis for metastatic tumours. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Bacterial infections are devastating and potentially lethal complications of acute pancreatitis, responsible for up to 80% of deaths in the condition. Pathogenetic studies of acute pancreatitis imply that the disease is initially a non-bacterial insult and that secondary sepsis frequently occurs during the progression of pancreatitis, concomitant with the...

From a historical perspective, the first experimental pancreatitis was induced by Claude Bernard in 1856 by the injection of bile and olive oil into the canine pancreatic duct, thus producing an acute necrotising pancreatitis. Since that time, acute experimental pancreatitis has attracted thousands of researchers, who employ animal models...

Despite intensive research and intervention, trauma continues to be the leading cause of death during the first three decades of life in the USA, and currently ranks as the fourth leading cause of mortality with over 160,000 deaths each year. Mortality following trauma occurs in three distinct periods. This article...

In the evaluation of any new cancer treatment, the use of appropriate experimental animal tumour models to bridge the gap between in vitro discovery and its eventual clinical testing is an important step. In vitro experimentation does not take into consideration the complex biological interplay among the host tissues,...

Hepatic fibrosis and cirrhosis of the liver are complex diseases which, in man, may be caused by such varied factors as alcohol, hepatitis, schistosomiasis, biliary atresia, malnutrition and exposure to carcinogens and hepatotoxins. Although hepatic fibrosis is characterised by the massive deposition of extracellular matrix components in the liver...

The development of the human biliary system has been studied extensively. This knowledge is essential to the understanding of the pathogenesis of a spectrum of diseases termed “ductal plate malformation” (DPM). This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

The pancreatic islets of Langerhans were described by Paul Langerhans in 1869. They are distributed throughout the entire pancreas forming in adults approximately 1% of the pancreatic mass. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Hepatic stellate cells (HSC) are mesenchymal cells that are prominent in various forms of liver injury, in particular with cirrhosis or carbon tetrachloride-induced fibrosis. HSC are also being increasingly reported around and within hepatocellular cancers (HCC), and have been thought to be responsible for the capsule formation in these...

Allogeneic tissue and organ transplantation has long been an important medical issue, as it provides an effective treatment alternative for a broad spectrum of medical problems. It is essential to establish the animal models used for a specific type of allogeneic tissue or organ transplantation prior to its clinical...

Although a number of data support the notion that mast cell (MC) degranulation Is an important component of the tissue response elicited by ischaemia-reperfusion, the role of the gastrointestinal MC system in the pathophysiology of postischaemic mucosal barrier lesions is still poorly understood. The mucosal MCs (MMCs) of the...

Despite the recent developments of minimally invasive surgery, most cardiac surgery procedures still include ischaemic cardioplegic arrest and cardiopulmonary bypass. For decades the efforts of many researchers aimed at improvement of cardioplegic solutions to minimise ischaemic injury of the myocardium. This article is available only as a PDF. Please click...

Primary hepatocellular carcinoma (HCC) is one of the commonest cancers in some parts of the world including several areas in China. The geographically distinct distribution of HCC indicates there are some special factors which play key roles in hepatocarcinogenesis. This article is available only as a PDF. Please click on...

Hepatocarcinogenesis is a multistage and multifunctional process. Epidemiological studies indicate that contamination of food with aflatoxin B, (AFB,) and chronic infection with hepatitis B virus (HBV) are the major risk factors for human primary liver cancer. This article is available only as a PDF. Please click on “Download PDF” on...

Nitric oxide (NO) has been recognised as a nonadrenergic noncholinergic (NANC) inhibitory neurotransmitter at various sites in the nervous system. Its function as a NANC inhibitory transmitter has been documented in muscular and sphincter relaxation in the cardiovascular, digestive and urogenital system. This article is available only as a PDF....

Osteoarthritis is a common joint disease that involves destruction of articular cartilage. Magnetic resonance imaging (MRI) provides a sensitive imaging modality for the diagnosis of osteoarthritis. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Allograft transplantation of bone has been established as a viable and useful reconstructive procedure when limb salvage is the option of choice. For bone allografts, this is thought to be due to the relatively avascular structure and that low-freezing or freeze-drying for periods beyond three months reduces cellular immunogenicity. This...

The direct intraluminal (IL) administration of drugs into the intestine may have an important regional action and therefore clinical implications in the effective management of functional bowel disorders. We have previously published findings in the anaesthetised in vivo pig, that cisapride and mebeverine when infused IL into the sigmoid...

Liver transplantation (LTx) is the treatment of choice for many patients with end stage liver disease. However liver allograft availability prevents its widespread application. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Bridging a vertebral gap in the spine is one of the commonest problems facing the spine surgeon after dealing with a tumour, infection or a fracture. The gold standard today is still the autogenous graft, though other solutions are the allograft, bone cement fashioned as a block, ceramics and...

Blood pressure is an important parameter commonly measured in experimental studies using animal models. Various non-invasive techniques to monitor blood pressure have been described in the literature but most of these are applicable only to small animal models like the rat. This article is available only as a PDF. Please...

Articular cartilage injuries to the knee are commonly seen by team doctors, sports physicians and orthopaedic surgeons. Despite many clinical as well as experimental studies on the healing of such defects, the ability to regenerate mature hyaline cartilage capable of withstanding daily functional stresses in the knee remains a...

Although the lung is mostly referred to as a respiratory organ it also exhibits a variety of metabolic functions, e.g. uptake, storage and/or synthesis and metabolism of compounds as different as biogenic amines, prostaglandins and angiotensin I. In spite of this vast metabolic capacity and the respiratory role of...

The application of the experimental approach to Science and Medicine has its roots in the 16th century. William Harvey (1578-1657), who demonstrated the passage of blood through the veins unidirectionally towards the heart as evidence for circulation of blood, was generally credited as one of the earliest physicians who...

The diagnostic tests currently employed to diagnose inflammatory bowel disease (IBD) and to differentiate between Crohn’s disease (CD) and ulcerative colitis (UC) are both expensive and invasive. Serological markers that are easily applied which can distinguish between CD and UC with comparable sensitivity and specificity are lacking. This article is...

Paclitaxel was discovered in 1963 as a crude extract from the bark of the pacific yew Taxus brevifolia. Since its development, a range of anticancer activity has been demonstrated. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Hepatocellular carcinoma (HCC) is a common malignant tumour worldwide. The local incidence of HCC is 40 per 100,000 in males and 20 per 100,000 in females. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Colorectal cancer incidence rates rank second in most developed countries and have been rising rapidly in urban societies of East Asia. Despite much effort to detect early-stage disease and to explore more effective treatment methods, the overall 5-year survival rate has remained around 40% based on the reports from...

Shigellosis is generally considered to be confined to the gastrointestinal tract. Septicaemic infections with Shigella species are extremely rare in adults. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder seen by gastroenterologists and has been found to account for 50% of referrals to a Gastroenterology clinic. It has an estimated prevalence of between 15% and 25% in the non-patient population. This article is available only as a PDF....

Helicobacter pylori is one of the commonest infections in human, affecting 30% to 50% of people worldwide. It is associated with the development of peptic ulcer, chronic gastritis and gastric cancer and may play a role in a small subset of patients with non-ulcer dyspepsia. This article is available only...

Gram-negative bacteria induced septic shock, a condition with high mortality, is frequently seen in critical care medicine. The wall of gram-negative bacteria consists of endotoxin, which is chemically composed of lipopolysaccharide, and is extremely biologically active. This article is available only as a PDF. Please click on “Download PDF” on...

Primary and secondary hepatic malignancies constitute a major health problem. Hepatocellular carcinoma accounts for 90% of all primary hepatic malignancies in the world. While relatively uncommon in Western countries, it is the most prevalent malignant neoplasm in Southeast Asia, South Africa, and many other regions. This article is available only...

The third edition of this manual of gastroenterology by regional experts from Malaysia and Singapore consists of 27 short chapters packaged in 2 sections entitled “Luminal gastroenterology and “Hepatobiliary & Pancreas.” In his preface, the editor, Dr Richard Guan, states that “our goal is to provide a resource for...

Adult polycystic liver disease (APLD) is a rare benign condition that is characterised by the growth of multiple cystic lesions in the liver. More commonly, it occurs in close association with autosomal dominant polycystic kidney disease (ADPKD), where the prevalence increases from 25% in the third to 80% in...

A 79-year-old Chinese woman with no significant past medical history was admitted to another hospital with symptoms of abdominal pain and haemetemesis of approximately 200 mL of blood after a severe bout of vomiting. She declined a oesophago-gastro-duodenoscopy (OGD) and was clinically diagnosed to have Mallory-Weiss syndrome. This article is...

Polyps of the colon and rectum are relatively common lesions. Most colorectal polyps are either adenomas or hyperplastic polyps. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Autoimmune liver disorders are inflammatory liver diseases characterised histologically by a dense mononuclear cell infiltrate, including plasma cells, in the portal tract (Fig. 1) and serologically by the presence of non-organ and liver-specific autoantibodies and increased levels of immunoglobulin G (IgG), in the absence of a known aetiology. They...

Inflammatory fibroid polyp is an uncommon nonneoplastic lesion found in the gastrointestinal tract. It is a benign, non-encapsulated submucosal lesion, composed mainly of loose connective tissues, vessels and with an eosinophilic inflammatory component. This article is available only as a PDF. Please click on “Download PDF” on top to view...

Parenteral nutrition (PN) is an important supportive and often life-saving therapy for patients with gut failure. However, it is expensive and carries significant complications such as electrolyte disturbances, hyperglycaemia, hypertriglyceridaemia, hepatobiliary complications and line-related complications. This article is available only as a PDF. Please click on “Download PDF” on top...

Acute hepatitis could result from viral, autoimmune or drug-reaction causes, among others. In areas endemic with hepatitis B, acute exacerbations of chronic hepatitis B (CHB) are the commonest cause. Hence, in Singapore where 4% of the population are hepatitis B carriers, when faced with acute hepatitis in a patient...

Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary method of diagnosing and treating many pancreatic and biliary diseases (PBD) over the last 3 decades. The development of endoscopic ultrasound (EUS) since its introduction in the early 1980s has added a new dimension to the treatment of PBD. This article is...

Coronary artery disease (CAD), also called coronary heart disease, is the leading cause of death for both men and women. CAD is usually caused by atherosclerosis. Atherosclerosis (the hardening of the arteries) is the most common form of arteriosclerosis, in which the walls of arteries become thicker and less...

The utility of ceftriaxone for the treatment of Salmonella typhi bacteraemia was first demonstrated in Singapore as early as 1985. Since then, ceftriaxone has become established as first-line treatment for typhoid fever and serious non-typhoidal Salmonella infections. This article is available only as a PDF. Please click on “Download PDF”...

Splenic abscess is an uncommon clinical problem. Fewer than 800 cases have been reported in the literature. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Colorectal cancer is now the cancer with the highest incidence in Singapore. Similar to many developed countries, individuals here have a moderate to high risk of developing colorectal cancer in their lifetime. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

This guideline addresses the use of endoscopic ultrasound (EUS) as part of the diagnostic evaluation of certain conditions. In addition, issues of training and credentialing in EUS and complications of this procedure are also dealt with, within these guidelines. EUS combines features of endoscopy and ultrasonography in order to...

A 79-year-old woman presented with fever, diarrhoea, vomiting and abdominal pain for several hours. Her temperature was 39.2°C, pulse 102 beats/minute, respiratory rate 19 breaths/minute, and blood pressure 149/74 mmHg. A physical examination revealed diffuse abdominal tenderness. This article is available only as a PDF. Please click on “Download PDF”...

Since its introduction a few decades ago, endoscopic retrograde cholangiopancreatography (ERCP) has brought about a significant change in the management of choledocholithiasis. With continual improvement in the technology and expertise in laparoscopic techniques, laparoscopic common bile duct exploration (CBDE) is becoming more popular and may be the next paradigm...

Peutz-Jeghers Syndrome (PJS) is an uncommon autosomal dominant hamartomatous polyposis syndrome associated with mucocutaneous melanocytic macules. Melanin deposition occurs most commonly in the perioral region and buccal mucosa, but these maccules may also be found on the hands, feet and perianal regions. This article is available only as a PDF....

Thalassaemia is a genetic haemoglobinopathy in which the production of normal haemoglobin is partly or completely suppressed because of a defective synthesis of 1 or more of its component globin chains. In haemoglobin (Hb) E beta-thalassaemia, an individual inherits 1 gene for Hb E from 1 parent and 1...

Thrombocytopenia is a common clinical problem found in laboratory results during health examinations. Blood platelets play an essential role in haemostasis, thrombosis and coagulation of blood. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Muslim individuals worldwide participate in obligatory abstinence from oral consumption of medications, food and liquid during the fasting month of Ramadan. Fasting during Ramadan is one of the 5 pillars of Islam. However, Islam exempts individuals whose health may be significantly affected from fasting. Despite this, up to 80%...

A total proctocolectomy is considered the standard of care in patients with ulcerative colitis (UC). The indications for this operation in patients with UC include failure of medical treatment or dysplastic changes following endoscopic evaluation. The timing of the surgery could hence be highly variable among patients. This article is...

Intestinal obstruction (IO) caused by malignancy and adhesion bands from previous surgery is common among adults. However, IO caused by congenital adhesion bands (CAB) in the elderly is rare. We report a case of a 63-year-old man who presented with acute-on-chronic intestinal obstruction due to CAB, which caused pseudointestinal...