Hepatitis C is one of the most common liver problems worldwide. It is estimated that around 10 million people are suffering from this illness in mainland China alone. In less developed countries, the most common routes of transmission are contaminated blood products or medical instruments. In more wealthy societies, people usually contract the disease due to high risk behaviours such as needle sharing and unprotected sex.

Up until 2014, the standard of care involves weekly injections plus oral medication for 6-12 months. These medications are associated with severe side effects, quite a number of patients cannot tolerate a full course of treatment; sadly some patients are even not eligible to start treatments. The worst thing is, after all this hassles, the rate of successful treatment for the most common subtype of hepatitis C in Hong Kong was only around 50%.

Good news is, since 2014, new drugs were developed. They are called direct anti-viral agents (DAA), each targeting one of the three different sites in the viral RNA. These drugs are pills, so no poking yourself every week, and the treatment duration is usually only around 3 months. Side effects are much less significant. Patients who previously failed treatments or not eligible to be given treatments, can now be treated as well. Overall success rate is around 95%! Well, the world is not perfect, good news always come with bad news…..money. A 3 month course of treatment now costs over half a million Hong Kong dollars. These drugs are not available in mainland China yet, so that 10 million sufferers in China are flocking to other countries for treatment.

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For the past couple of years, there is a lot of news on colorectal cancer screening from various academic bodies such as, and especially, The Chinese University of Hong Kong. Finally, the Hong Kong government is launching the pilot screening program this year. What’s the fuss about colorectal cancer? Sure, it’s a common cancer, but so does lung cancers, liver cancers etc, why not a screening program for the other cancers?

Well, for a disease to be “worthwhile” for a population-wide screening program, it first has to fulfill a set of criteria: the Wilson and Jungner screening criteria. Briefly, it means that if there is an illness of significant health risk to the general population and somehow we have cost-effective means to do something to prevent it, then we should consider screening. So far, the only cancer that fulfill the criteria is cervical cancer, prevented by regular pap smear, up until now. Colorectal cancer is the number 1 or number 2 (depends which year) cancer in Hong Kong, so it’s a major health burden. We know that most colorectal cancer arises from polyps on the inside wall of the colon, and polyps could slowly grow into cancer in around 10 years, therefore we have a 10 years period to remove the polyps before they become cancers.

We have 2 effective ways to detect polyps. Most cancers and some polyps bleed, so we can test stools for blood and if blood is detected we perform a colonoscopy. The disadvantage is that most polyps do not bleed, that’s why stool tests are more for cancer detection rather than cancer prevention. Studies have shown that stool testing can only prevent 15-33% of colonic cancers. The other way to do it is by endoscopy, either just look at the lower part of the colon (sigmoidoscopy) or the whole colon (colonoscopy). Sigmoidoscopy causes less discomfort and can be done without sedation; however it misses polyps further up in the colon. Colonoscopy is the most effective way to screen for polyps, but also the most expensive.

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Gallstones are most commonly found in the gallbladder. Due to the close proximity of the gallbladder to the tummy wall, gallbladder stones are easily detectable by simple ultrasound over the tummy (transabdominal ultrasound), and of course CT and MRI scans. When the stones are just sitting there, not causing any pain, inflammation or infection, we can just leave it. Unfortunately, stones sometimes sneak into the bile ducts causing pain and infections, i.e. cholangitis; and the adjacent pancreas can be affected as well resulting in pancreatitis.

Initial symptoms are just tummy pain and fever, overlapping with numerous other illnesses. As it progresses, jaundice (yellowish eyes) may develop as result of blockage of bile flowing through the bile ducts. Blood work may shows elevation in liver enzymes, bilirubin levels, amylase, and inflammation markers and so on. However, it may be difficult to differentiate biliary stone diseases from malignant biliary tract, liver and pancreas diseases. Imaging is of ultra importance to make a firm diagnosis. Unlike the gallbladder, the bile ducts are hidden deeper in the tummy and transabdominal ultrasound has limitations on ruling out the presence of biliary stones.

Endoscopic retrograde cholangiopancreatogram (ERCP) used to be the most important investigative and therapeutic tool for biliary and pancreatic diseases for decades. It involves putting a tube through the mouth into the small bowel, and from there instruments are introduced into the bile ducts. However, diagnostic ERCP is currently virtually non-existent in developed regions of the world as other safer investigative modalities are available, namely magnetic resonance cholangiopancreatogram (MRCP) and endoscopic ultrasound (EUS). Complications arising from diagnostic ERCP (e.g. perforation of the bowel wall, pancreatitis) certainly would lead to medico-legal issues. Nowadays, after the diagnosis of biliary stone disease has been made by MRCP or EUS, ERCP will then be performed to clear out the stones.

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Inflammatory bowel disease (IBD) involves chronic inflammation of all or part of the digestive system. Generally speaking, IBD includes ulcerative colitis and Crohn’s disease. The most common age of onset is between 20-40 years old; however, new onsets of the disease can be seen in children and elderly as well. Etiology of IBD is multi-factorial, environmental factors, genetics, infections and immune system intertwined leading to the immune system erroneously attacking the patient’s own digestive system. Symptoms of ulcerative colitis and Crohn’s disease are very similar. Patient may suffer from tummy pain, diarrhea, blood mixed with stool, and weight loss due to decreased appetite and malabsorption. Besides symptoms of the digestive system, patients may also have inflammations in the joints, eyes, skin and bile ducts.

Ulcerative colitis mainly affects the colon and rectum, and causing inflammation at the innermost lining of the colon and rectum. Crohn’s disease, on the other hand, may affect anywhere of the digestive tract from the oral cavity down to the anus, and causing inflammation across all the layers of the digestive tract from the inside to the outside, sometimes affecting nearby organs. There is no definitive test to differentiate the 2 diseases. Gastroenterologist need to gather clinical information, blood tests, endoscopic findings and histology results in order to make a diagnosis. Tuberculosis infection of the digestive tract may present similar to Crohn’s disease, so extra care is needed to rule out infection before starting treatment.

Treatment strategy of IBD involves suppression of immune system with steroids and/or other immunosuppressive medications. Recent development of biologics allows control of more severe or refractory diseases. For uncontrollable ulcerative colitis, surgical removal of the whole large bowel is essentially a cure. The role of surgery in Crohn’s disease is to alleviate complications such as bowel obstruction, perforation of bowel wall and abnormal tracts connecting the gut to adjacent organs. IBD must be persistently and effectively controlled to avoid or minimize life-threatening complications and colonic cancers.

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發炎性腸病

發炎性腸病（炎症性腸病）一般而言包括兩種疾病：潰瘍性腸炎及克隆氏症。這兩種慢性腸道疾病的發生原因可能與環境因素，基因，感染和免疫系統的互相作用有關，導致身體的免疫系統錯誤地攻擊腸道。最常見發病的歲數為20至40歲，但也可能在兒童和老人家發病。兩種病的症狀非常近似，包括腹痛、腹瀉和大便有血、因為胃口欠佳和營養吸收功能受捐導致病人體重會持續下降。除消化系統外，其他相關症狀包括關節炎、壞疽性膿皮症、眼色素層炎及硬化性膽管炎。

潰瘍性腸炎一般只影響大腸，而且只是腸道內的表層黏膜發炎。克隆氏症則可影響腸胃道內從口腔至肛門的任何部分，而發炎可由腸道內層至腸道外層及影響附近的器官。現在沒有特定方法將兩種病距分，醫生要根據臨床診斷，血液化驗結果，內視鏡檢查和抽取腸壁組織檢查來幫助診症。有些克隆氏症病人的病症跟腸結核非常相似，一定要小心排除後者才能確診。

發炎性腸病的治療需要長期服藥來壓抑炎症，如類固醇及其他抑制免疫系統藥物。近年開始使用的生物製劑可改善較嚴重的病情。病情最嚴重的潰瘍性腸炎病人可選擇將大腸切除而得到控制。克隆氏症患者可能出現併發症如腸道因腫脹而做成阻塞，腸道穿破或黏連至其他器官，需要外科手術治療。發炎性腸病病情必須長期受控，否則會有機會出現致命的併發症或大腸癌。

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Helicobacter pylori infection plays an important role in the pathogenesis of peptic ulcer diseases and stomach cancers. It is classified as group I carcinogen by the World Health Organization’s International Agency for Research on Cancer in 1994. Back in 1940, Freedburg and Barron have already reported the histopathological finding of spirochetes in surgically removed stomach specimens, preceding the success in culturing this organism by Warren and Marshall in 1983 in Perth, Western Australia. Its prevalence worldwide is approximately 50%, but highly variable among socioeconomic and geographical factors. The infection is usually acquired in childhood, and strongly associated with low socioeconomic status. The prevalence in children can be as low as 5% in developed countries compared with over 80% in developing countries. In Hong Kong, recent data suggest that its prevalence in adult patients has dropped from 50% to 32% over the last decade.

Different diagnostic modalities are available. Non-invasive methods include ¹³C-Urea breath test, stool, urine and blood tests. ¹³C-Urea breath test is particularly convenient for patients without any alarming symptoms. For patients whom more sinister disease is anticipated, upper endoscopy to obtain stomach wall specimens is recommended. Treatment regimens include the use of proton pump inhibitors to suppress stomach acidity and a combination of antibiotics targeting Helicobacter pylori for 1-2 weeks. Successful rate of eradication is around 90%. At least 4 weeks after treatment, another ¹³C-Urea breath test can confirm treatment success.

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幽門螺旋菌
幽門螺旋菌是一種只存活於胃壁的細菌，但全球約一半人口都已受感染。對於此細菌的傳播途徑，醫學界還沒有定案，但相信是在兒童時期受感染的。幽門螺旋菌引發的胃病可輕可重，他可引發慢性胃炎，胃潰瘍，十二指腸潰瘍及甚至胃癌。世界衛生組織已將幽門螺旋桿菌列為第一級的胃癌致癌因數。可幸是此細菌的發病率只是約10%，即大部分受感染人士都沒有病徵。而因為香港居住環境衛生有所進歩，受感染人口已由過往的50%下降至約30%，年輕一代的感染率應該更低。

上消化道內視鏡及抽取胃壁組織檢查可準確診症。對於非胃癌高危人士，C13吹氣測試是相對較方便的檢查來確認患者是否有感染幽門螺旋菌。治療方法是使用包括 proton pump inhibitors 的藥物減低胃酸及服用針對幽門螺旋菌的抗生素，服用七至十四曰後，清除幽門螺旋菌的機會率約百分之九十，患者可在服藥後最少四個星期再進行C13吹氣測試，以確認是否仍有病菌。病菌清除後翻發機會低於1%，而且清除病菌是有效防止胃潰瘍或胃癌的方法。

Dr-ernest.net

In Cantonese, there is a saying “yellow faced women” that describes unattractive middle aged housewives. It probably comes from the fact that pre-modern era makeup contains lead; it is toxic and causes discoloration of the face after long-term usage. Is it also true that yellowish face indicates the suffering of liver diseases?

Yes. But doctors generally do not look at skin color to diagnose patients with liver disease, we look at the conjunctiva (the white of eyes), where the detection of yellowish color could be earlier. The yellow color reflects the accumulation of bilirubin. Every day, aged red blood cells break down into bilirubin, bilirubin is metabolized in the liver and passed out of our body in bile through our gut. Bilirubin is the pigment we see in bile, golden yellow, and also gives the brownish color in our poops. Patients with acute or chronic liver failure will accumulate bilirubin in the body, leading to yellowish discoloration of skin and mucous membranes, particularly apparent on the originally white conjunctiva.

In Hong Kong, the major causes of acute hepatitis are due to viruses, drugs and herbs.

Viral infections are mainly hepatitis A, B, C, and E. Hepatitis (hepatitis A) is a gut infection. Virus comes from the stool of infected persons, and then through unclean food, water, or contaminated hands to other people. Therefore, route of infection is usually eating virus-contaminated water and undercooked food (especially oysters, clams, mussels and scallops, etc.). Every year, there are hundreds of cases in Hong Kong. Hepatitis E is transmitted similarly as hepatitis A, but there is evidence that it can spread through eating raw or undercooked meat. The virus is also found in pig liver, but the importance of this route of transmission remains uncertain. Pregnant women should pay special attention because hepatitis E infection in pregnancy ladies has a mortality rate of approximately 20%! And there is no vaccine or cure against this virus. Acute hepatitis B and C are transmitted through sexual contact or blood, such as needle-sharing.

Drugs, be it modern medicines or traditional Chinese herbs, mostly rely on liver to metabolize. So some drugs can cause acute hepatitis. Hong Kong Chinese like to take herbal medicines, not only for sickness but also for general healthiness, making herbs-induced hepatitis a common condition on Hong Kong. It is important to know that drug related hepatitis has no cure, in the event that the liver cannot recover by itself, the only solution is liver transplant!

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肝病=臉黃？

女士們都會不悦给他人稱為黃臉婆。聞說古代女性所用的化妝品含鉛，有毒性，長期使用會導致臉色變黄。所以年長女士成了黃臉婆。其實肝病是否都會導致臉黄？

是。不過醫生一般不會依賴皮膚顏色去診斷病人有肝病。我們會觀察病人的眼白有否呈現黄色。觀看眼白比起觀看皮膚更容易及早和準確地察覺到變化。眼白越黃，病情可能越嚴重。為什麼會黃？因為膽红素(bilirubin)。血液(紅血球) 每日都會因為新陳代謝而產生膽紅素，膽紅素由肝臟經膽汁排出腸道。膽紅素是膽汁主要的色素，為金黃色，亦是大便的主要色素。急性肝炎或肝硬化病人的膽汁排泄不順，膽紅素累積在血液中，會讓皮膚和黏膜顏色變黃，尤其是原本白色的眼結膜就更加明顯。

在香港，急性肝炎主要由過濾性病毒，藥物和中草藥引起。

過濾性病毒主要分甲，乙，丙，戊。甲型肝炎(hepatitis A)是由腸道傳染的。病毒由病人的大便中排出體外，再經由不潔的食物、食水，或沾染病毒的雙手傳入其他人口中而導致傳染。因此感染途徑通常是進食被病毒污染而未經煮熟的食物(尤其是蠔、蜆、貽貝和扇貝等) 或飲用未經妥善處理的食水。香港每年都有幾百宗病例。戊型肝炎(hepatitis E)的主要傳播途徑跟甲型肝炎一樣。但也有證據顯示，傳播可經進食生或未經煑熟的肉類。在豬肝臟亦曾發現戊型肝炎病毒，但這種傳播途徑的重要性仍未確定。孕婦要特別注意。因為孕婦如感染戊型肝炎，死亡率是大約20%的！而現在還沒有疫苗可預防此病毒。急性的乙型和丙型肝炎是經性接觸或血液傳染，如共用針筒。

藥物，無論是西藥，中成藥，或中草藥，大多依靠肝臟分解，然後排出體外。所以有些藥物是會引發急性肝炎。因香港人服用中藥很普遍，中藥引發的急性肝炎亦多。建議切忌自行用藥，因嚴重者是要靠肝臟移植續命的。

更多資訊: Dr-Ernest.net

Some people have the concept that bowel movements equal detoxification. If it’s true, then having regular bowel movements should make you feel good, right? Some people suffers from bloated tummy despite having daily bowel movements, why is that? The most common reason is irritable bowel syndrome, generally known as “gut -sensitivity.” Most patients develop symptoms in their twenties. Cause of irritable bowel syndrome is not fully understood, it is believed to be related to emotional stress, sleeping disorders and eating habits and so on. During exacerbation, symptoms such as tummy pain, bloating or discomfort are common, and usually partially relived by toileting. Both diarrhea and constipation can occur, stool consistency can be hard or watery, and mucus discharge may present. Of course, most people occasionally have the above problems, but if the symptoms are frequent or affecting their social life, then he/she may be suffering from irritable bowel syndrome. Severely affected patients will have fear of going out or socializing for fear of needing a bathroom; incontinence is seen in extreme situation.

Irritable bowel syndrome has no specific medical test; making the diagnosis relies solely on symptoms. Doctors usually recommend taking stool samples for laboratory testing and endoscopic investigations. Endoscopy can eliminate some of the more serious diseases such as colorectal cancer, inflammatory bowel diseases (such as Crohn’s disease and ulcerative colitis), and infectious bowel diseases (such as tuberculosis). If all tests are normal, but symptoms persist, the chance of irritable bowel syndrome is likely.

Patients should pay attention to diet and avoid high FODMAP diet. High FODMAP containing food include fructose ( such as apples, pears, mango , watermelon ) , lactose ( such as milk , cheese, soft cheese ) , oligosaccharides ( such as the West orchids, onions, wheat ) and polyols (such as a sugar substitute for chewing gum and sweetener sorbitol and xylitol). Probiotics is also helpful in some patients.

According symptoms of this disease can be divided into (1 ) diarrhea type , ( 2 ) constipation type , ( 3 ) mixed type , and ( 4 ) non-categorical type. For each particular patient, his/her symptoms and hence classification may also change in time. Irritable bowel syndrome has no “cure”, the main goal of treatment is to ease symptoms. Doctors will prescribe medications based on symptoms and the severity of the patient. Patients with mood disorders should receive appropriate mental health treatment. When the mental health is well, gut symptoms may be improve.

Blog: dr-ernest.net

什麼是腸敏感?

有些人仕覺得大便暢通等於排毒。但如果日日都有排便，仍然腹部脹脹，又點解呢？最常見的原因就是腸易激综合症，一般人稱「腸敏感」。患者多於二十多歲時首次發病。醫學界對腸易激综合症的成因未完全明白，但相信與壓力過大，情緒緊張，睡眠失調和飲食習慣等有關。病發時會有腹痛，腹脹或腹部不適，而排便後會得到一定的紓緩。同時亦會有肚瀉或便秘，大便過硬或呈水狀，或大便時有黏液排出。當然一般人偶然也會有以上情況，但若症狀頻密或影響日常生活，便有可能是患了腸易激综合症。嚴重的患者會因為害怕需要找洗手間而減少外出和社交活動，甚至乎失禁。

腸易激綜合症沒有特定的確認檢查，只能倚靠病徵確診和分類。所以醫生一般會建議取大便樣本作化驗和內視鏡檢查。內視鏡檢查能夠排除一些更嚴重疾病如大腸癌，免疫系統性腸炎(如克隆氏症，潰瘍性腸炎)，和感染性腸炎(如過濾性病毒，肺癆菌)。如所有檢查結果正常，而病徵持續，很大機會是患上腸易激綜合症。

患者要注意飲食，避免高”腹鳴”食品 (FODMAP diet). 高腹鳴食品包括果糖(如蘋果，梨，芒果，西瓜)，乳糖(如牛奶，乳酪，軟芝士)，寡糖(如西蘭花，洋蔥，小麥)和多元醇(如用於香口膠和作代糖的甜味劑sorbitol和xylitol)。益生菌亦對一些患者有幫助。

根據病徵，此症可分為(1)肚瀉型，(2)便秘型，(3)混合型和(4)無法分類型。而患者亦可能隨時改變徵狀和類型。腸易激综合症並沒有根治的治療，治療的目的主要為緩和病徵。醫生會根據患者的病徵及嚴重程度選擇藥物。如患者有情緒病，亦應接受適當治療。當情緒病得到控制，腸胃症狀亦會紓緩。那就不需要想法子遮蓋脹起的腹部。

網誌: dr-ernest.net

As a doctor, friends often ask me for medical advices. It came to my notice that a lot of young women are plagued by constipation, although many cases are not severe enough to require medication, but basic recommendations such as eating more fruits and vegetables, drinking plenty of water and exercising are not helping. One important factor is timing. A flight attendant, for example, has her toilet time messed up by work frequently. Assuming a flight from Hong Kong to Toronto, flight time of ~14 hours, she has to report duty 2 hours before departure, and takes another hour to get to hotel after arrival. That is a total of 17 hours when she could not or prefer not to go to the toilet even if her body urges her to. After completion of 17 hours work, both physically and mentally exhausted, would she rather sleep or poop at the hotel? By the time she wakes up, the urge is gone. Besides, location is an important factor, despite how nice a hotel room toilet is, a toilet in an unfamiliar environment is always screaming “it does not feel like home!” Furthermore, her physiological clock is constantly disrupted due to time differences between cities.

Habitual constipation can cause tummy bloating, because the accumulation of feces in the colon. Feces increase intestinal bacteria cause bad breath. Most people have constipation are helpless and embarrassed, and there could be severe emotional stress, sleep disorders and depression.

Coming back to business women, most cases are not as bad as aforesaid, but work messing with toilet time seems inevitable. In fact, to solve the problem, the most basic thing is to follow your “gut”. When your body tells you to go, you go. If you’re accustomed to “ignore” it, the rectum (lowest part of the colon) will gradually get used to store the feces, feces staying in the large bowel for a long time will harden, leading to a vicious cycle. Of course, eating high-fiber foods (such as cranberries, prunes, pear skin, green beans, broccoli, wheat bran, oat bran, rice bran, etc.) plus drinking enough water can soften the stool. I recommend daily consumption of 6-8 glasses of water, warm water than cold water helps stimulate bowel movement, and reduce drinking coffee and alcohol because both cause moisture loss. Exercise, as simple as 30 minutes of brisk walking, can help stimulate intestinal peristalsis. Finally, the best action is to develop a regular toilet habit. At the same time each day, set aside 20 minutes to sit in the toilet at home, the best time is half an hour after eating, because eating stimulates large bowel movement, especially after breakfast. In time, your bowel movement would run like a German train schedule.

Hope these points can help some of you.

Blog: dr-ernest.net

有口難言

作為醫生，身邊朋友經常都會向我詢問一些醫學問題。原來好多年輕女性都受便秘困擾，雖然很多個案也未必未嚴重到需要服藥解決，但基本建議如多食蔬果、喝水和運動對他們的幫助有限，最重要還是時間性。

以一位空中服務員為例，她的如廁時間非常受出勤工作影響，假設由香港飛往多倫多，機程要14小時，起飛前2小時要回公司報到，落機後要約一小時才到酒店。如果上班前無大便，在航程上又因為當值而忘記了，起碼要忍17小時。當她完成17小時工作後，身心俱憊，到當地酒店應該便已倒頭大睡？睡醒時，早前的便意經已消失，再加上時差因素，生理時鐘也未適應而打亂了。此外，地點也是重要因素，先說機內廁所衛生情況只屬一般，而無論下榻酒店如何星級，一踏入陌生環境的洗手間，只可軟嘆 “it never feels like home！”。好了！幾天後當身體已適應了當地時差後，又要回港，就是這樣幾天她也沒有排便了。

習慣性便秘會導致腹脤，原因是結腸積聚了宿便。宿便會增加腸道細菌導致有口氣。一般人面對便秘是無奈又尷尬，但嚴重者會有情緒緊張，睡眠失調和憂鬱症。

說回在職女性，大部份情況應沒有上述般糟糕，但因為工作而影響如廁時間在所難免。其實要解決問題，最基本是有便意就應該上洗手間。如果你習慣了「忽視」便意，直腸漸漸地習慣了儲存大便，便意就隨之減少，當大便在大腸停留久了便會變硬，導致惡性循環。當然多吃高纖食物(如紅莓，西梅，梨連皮，青豆，西蘭花，麥糠，燕麥糠，米糠等)加上多飲足夠水分是可以軟化大便。每日最少要喝6至8杯水，天氣炎熱時或多汗者要喝多些。喝暖水比喝冷水更能夠幫助刺激正常的腸道蠕動。受便秘問題困擾者就要減少喝咖啡及酒，因為兩者會使水分流失。運動方面，簡單如30分鐘的急步行，可以幫助刺激腸道蠕動，也可減少便秘。最後，最理想當然是養成有規律的上洗手間習慣。每天在同一時間預留20分鐘安坐於家中洗手間，最好當然是進食後半小時，因為在進食時大腸蠕動幅度比較大的，特別是早餐後最容易有便意。久而久之養成習慣便可。

除非你是空中服務員或因公事常常出差，但以上意見應該可幫到一班備便秘因擾的在職女性朋友。如往外地工，最有效的方法就盡快適應時差，回復正常生活規律。

Blog: dr-ernest.net