Some common myths set aside
FROM being the way to a man’s heart, the stomach is today the way to a plethora of diseases. Your chances of getting heart diseases, hypertension, diabetes, and many other lifestyle diseases are to a large degree informed by what goes into your stomach and in what quantity. Well then, what about the stomach itself?
Dr. Iqbal Siddique, a gastroenterologist at the Amiri Hospital, in this interview provides a brief overview of the commonly found diseases of the stomach, how they can be treated, and what factors trigger their onset and influence their progress. Dr. Siddique puts in perspective a variety of diseases from Irritable Bowel Syndrome to colon cancers, breaking some myths on ulcers in between. Also find out how Crohn’s Disease, which has historically been sighted only in the West, is now finding new pockets of prevalence in Kuwait.
Question: What are some of the common gastroenterological diseases you see in Kuwait?
Answer: As a gastroenterologist, the majority of cases I see can be broadly divided into three categories. The first group is what is known as functional gastrointestinal disorders. The common symptoms in this group of disorders are abdominal discomfort or pain, complaints of gas or bloating, as well alternating diarrhea, and constipation.
These symptoms are usually present for several months, or even years. Depending on the combination of the symptoms, these are diagnosed as Irritable Bowel Syndrome (IBS) or functional dyspepsia. Locally it is usually referred to as “Nervous Colon”. These patients usually undergo several tests to evaluate their gastrointestinal tract, which are usually normal. Functional gastroenterological disorders are common all over the world, not just in Kuwait. The underlying cause for these types of disorders may be related to the personality of the patient in addition to diet, lifestyle, and stress, and so on.
The second group of diseases is Inflammatory Bowel Disease (IBD), which results from, as the name suggests, inflammation in the intestines. These are chronic, relapsing, inflammatory processes that affect the gastrointestinal tract resulting in long-term morbidity. The two most common types of inflammatory bowel diseases are Crohn’s Disease and Ulcerative Colitis. These are caused by the body’s immune system acting against the body itself, specifically the intestines. This leads to damage to the intestines, such as ulcers in the small bowel and colon leading to pain, diarrhea, diarrhea with blood, weight loss, etc.
Moreover, these diseases are immune-mediated, and the immune system can also affect other parts of the body such as the joints, skin, and eyes. In a majority of the cases, the intestines are the main target of the immune system, but when it also affects other parts of the body we call it extraintestinal manifestations of IBD.
The third group of diseases in gastroenterology is those related to the production of acid in the stomach. These included peptic ulcer disease, which affects the stomach and duodenum, and gastroesophageal reflux disease, which results from acid coming back into the esophagus from the stomach and causing heartburn or acidity.
Broadly, these are three major groups of gastroenterological diseases that we see: functional diseases, inflammatory diseases, and acid-related diseases.
Besides these we also see different kinds of tumors in the gastrointestinal tract such as the colon, esophagus, and stomach. The gastroenterologists play an important role in the diagnosis of these tumors and along with the surgeons and oncologists play an active part in their management as well. We also see diseases of the pancreas, liver, and biliary system.
Q: Are the inflammatory bowel diseases in any way related to rheumatoid arthritis?
A: It is believed that the immune-mediated diseases occur because of alterations in the mechanisms that regulate the immune system in the body along with the interaction between genetic and environmental factors. Inflammatory bowel diseases and most rheumatologic diseases are immune-mediated. As I mentioned before, inflammatory bowel diseases can also affect the joints, skin, and in some cases, the eye. So these diseases are similar in those terms. Some features of these diseases can present in the same way, and sometimes these are treated in the same way with medications that act on the immune system, such as a new group of medications known as a biologic treatment.
Q: Are there any specific conditions that expatriates present because most of them live without families and regularly eat out?
A: The good thing about Kuwait is that the hygiene levels at the restaurants are usually good because the ministry enforces it. We usually do not see problems that we see in other countries where when people eat outside they get diarrhea or food poisoning. We do not see such problems in Kuwait.
However, most expatriates who live in Kuwait without families and have to eat at restaurants usually eat unhealthy food such as fast food, or food rich in fat, oil, or spices. This may result in weight gain, as well as symptoms such as reflux and heartburns.
Q: So what alternatives do you suggest? If one has to eat from outside, how best can he reduce the negative effects of it?
A: Unfortunately the choice is limited. Most restaurants serve food rich in fat or spices. Nobody really cares to make healthy food. So, these people should try their best to order food that is less oily, such as fried items. They should try and order more salads, vegetables, lentils, daals, etc. The other important thing to remember is not to overeat. No matter what kind of food you eat, if you overeat you are going to have problems such as weight gain, bloating, and acid reflux.
Q: Some say that yogurt is good for ulcers as it is gentle on the stomach lining, is that true?
A: Yogurt may give temporary relief, but it doesn’t heal the ulcers. Many people believe that ulcers are usually caused by spicy food and that yogurt coats the inner lining of the stomach and hence is good for ulcers. The other myth is that a stressful lifestyle causes ulcers. These beliefs are not correct. It is well known these days that the majority of ulcers are caused by a bacterium called Helicobacter pylori. Most people get infected by this bacterium at a younger age and later may get an ulcer because of it. The second common cause of ulcers, besides the bacterial cause I just mentioned, are medicines like aspirin or medication that people use for joint pains known as non-steroidal anti-inflammatory agents. These medicines can also damage the lining of the stomach as well as the intestines and cause ulcers.
Q: How do people contract Helicobacter pylori?
A: Helicobacter pylori is the most common chronic bacterial infection in humans. It is usually transmitted from person to person most probably by what is known as the oro-oral or oro-fecal route. It is estimated that close to 50 % of the world’s population is infected with this bacterium. As I said it is usually contracted in childhood and resides in the person for a long time and its prevalence is related to the socio-economic conditions. The infection rate of children in developing nations is higher than in Western nations, probably due to poor sanitary conditions. In developed nations, it is currently uncommon to find infected children, but the percentage of infected people increases with age, with about 50% infected for those over the age of 60 compared with around 10% between 18 and 30 years. The higher prevalence among the elderly reflects higher infection rates when they were children rather than infection at later ages. So, it’s a sign that with improvement in the living standards the number of people getting infected with Helicobacter pylori is dropping.
Similarly in Kuwait, where living conditions have improved greatly, the prevalence of this bacterium is also expected to decrease, especially in children and young adults.
Q: You said it’s a myth that ulcers are caused by stress. But you mentioned stress as a cause for functional diseases. Tell us something about that.
A: Yes, psychological stress is widely believed to play a major role in functional gastrointestinal disorders, especially Irritable Bowel Syndrome, by precipitating exacerbation of symptoms. Multiple factors – biological, psychological, and social – play a role in the development of functional gastrointestinal disorders. Research suggests that stress may be particularly important, however. The relationship between environmental or psychological stress and gastrointestinal distress is complex and bidirectional, i.e. stress can trigger and worsen gastrointestinal pain and other symptoms, and vice versa. This is why psychological therapies are often used in combination with other treatments, or even on their own, to treat functional gastrointestinal disorders.
As I mentioned earlier, peptic ulcer disease usually results from Helicobacter pylori or certain medications. However, patients suffering from functional gastrointestinal disorders such as functional dyspepsia may actually have pain which is very similar to ulcer pain. The difference is that in functional dyspepsia test; say an endoscopy will be normal while in ulcer disease it will show an ulcer.
Q: Can you explain how stress causes these problems?
A: We all have a nervous system. When we talk of the nervous system, we only think of the brain and the spinal cord. But there are also a lot of nerves in the GI tract, which make up what is known as the enteric nervous system. The enteric nervous system controls the normal movement of the alimentary tract, which is the mechanism responsible for the propulsion of food down the intestines.
In some people these nerves in the gastrointestinal system might be hypersensitive. When someone who does not have functional gastrointestinal disorder eats something that stimulates or irritates these nerves, he or she might feel a little bit of discomfort for some time but may ignore it and it will get over with time. But if someone with hypersensitive nerves eats the same food, it could trigger a whole lot of problems. This is because these hypersensitive nerves many send exaggerated messages to the brain, and if the person has stress, it adds to the problem.
Moreover, stress also triggers different reactions in people for the same symptoms. People under stress may seek more attention, especially medical attention. For instance, when a person under stress comes to me with gastrointestinal symptoms and based on my evaluations and tests, I declare he or she has a functional problem, the patient might go to another doctor thinking I could have missed something in his or her diagnosis.
Q: How prevalent are the immune-mediated intestinal diseases like saying Crohn’s disease in Kuwait?
A: Inflammatory Bowel Disease, especially Crohn’s disease, is something you see more in the Western countries, especially in the Northern part of the Western world, like Northern Europe and North America and not so much in South America, Southern Europe or Asia.
But I was surprised to see many patients with Crohn’s disease when I came to Kuwait. I did my training in the US, and when I came here, I found that there are many patients with Crohn’s disease in Kuwait and some parts of Saudi Arabia.
In fact, in the Middle East, especially the Arabian Gulf, Kuwait, and Saudi Arabia have reported more patients with Crohn’s disease than the UAE, Qatar, Egypt or other parts of the region. So, it appears that we have a pocket of Crohn’s disease in Kuwait and Saudi Arabia.
Q: You said it’s more prevalent in the northern part of Western countries. Why?
A: Crohn’s disease has a genetic predisposition, so it is possible that the populations in these regions are more predisposed to this disease than those in the Southern regions. Secondly, this is a disease which has been linked to several of the aspects of modern life and higher socio-economic status. It is well known that countries in the north have a higher standard of living than the south. So if people belong to higher socioeconomic strata and if they have a genetic predisposition to Crohn’s disease, then they tend to get this disease.
Similarly, the pocket of Crohn’s disease that I mentioned in this part of the world is probably genetically predisposed. This region has witnessed great economic progress, followed by modern lifestyle, hygienic living conditions and western type of diet in the last 30 to 40 years. This coupled with genetic factors could be the reason for Crohn’s disease in Kuwait.
Q: Tell us about the topics you tackled at the recently held IMID conference?
A: IMID stands for “Immune Mediated Inflammatory Diseases”. There are several diseases which are immune mediated, such as Inflammatory Bowel Diseases, inflammatory conditions of joints and skin. Usually these are seen and managed by specialists in gastroenterology, rheumatology or dermatology. The IMID Conferences provide a forum for experts in these three specialties to come together and share their experiences in dealing with immune related intestinal, skin and rheumatologic diseases.
There are several aspects that tie these disorders together. Mainly they are all immune related, and secondly I, as a gastroenterologist, may use the same medications to manage these disorders that a dermatologist or a rheumatologist might use, because though the problems might be different, they all have the same underlying mechanism which is the problem in the regulation of the immune system.
IMID is a platform for us to exchange ideas, update ourselves on the latest developments and recommendation, and compare guidelines used in the treatment of these diseases.
IMID is one of the very few conferences, where you have experts from different specialties coming together. We learn from each others’ experiences because these diseases are tied not only in their mechanism but also their treatment. The group which use biologic medications the most frequently are the rheumatologists. So, they have the longest experience in this field. They can tell us the most about the challenges in the use of these agents.
Q: What came out of the conference? Any new developments?
A: There is always something new that you learn from conferences. It is not necessarily a major breakthrough every time, but there are always some new developments, even if minor. For example, the major topic of the last IMID Conference in Dubai was how to monitor patients’ who are being treated with biologic agents, how to decide how long the treatment should be given, what are the criteria for to considering stopping these agents, and how patients fare once the treatment is stopped, how many show a relapse… those kind of things.
Q: What about stomach cancers? Are they prevalent in this part of the world? Cancers in general are on the rise.
A: We do see stomach cancers here but not very frequently. The worldwide incidence of stomach or gastric cancer has declined rapidly over the recent few decades. Part of the decline may be due to the recognition of certain risk factors such as Helicobacter pylori and other dietary and environmental risks. The reason for that could be better lifestyle. Also, as I said earlier, the frequency of the Helicobacter pylori is decreasing, especially the developed world, leading to a fall in ulcers and stomach cancers.
The cancer we see the most commonly in the gastrointestinal tract, in Kuwait, is colo-rectal cancer. It is the most common cancer in men in Kuwait and the second most common in women. We also see colon cancers in some families that have a genetic disposition to it. In general, the prevalence of colo-rectal cancer in Kuwait is less than what you find in the west, but higher than other Arab countries.
Q: Obesity, which has increased rapidly due to modern lifestyle, is one of the causes for cancer. Then shouldn’t the increase in obesity show a proportional increase in cancers? You say stomach cancers have dropped.
A: You are correct that obesity is increasing in Kuwait. Obesity is a cause for heart disease, arthritis, diabetes, hypertension and many other conditions. Obesity is a risk factor for most kinds of cancers and has also been shown to be associated with stomach cancer. That may have to do with how the body responds to obesity in terms of certain chemicals that are produced.
However the incidence of cancer of the stomach is decreasing. The two major risk factors for stomach are Helicobacter pylori and lower socioeconomic status. The World Health Organization has classified Helicobacter pylori as a class I carcinogen for gastric cancer. Stomach cancer has been found to be inversely related to socioeconomic status with an inverse association between level of education or income and stomach cancer risk. As the prevalence of Helicobacter pylori is decreases and living conditions improve the rates of stomach cancer also decrease. The country with the highest rate of stomach cancers historically has been Japan. Even in Japan the incidence is decreasing, though this decrease is slower compared to the western countries. It is possible that with an increase in obesity we may see a reversal in the decreasing trend of stomach cancer.
Q: What is your general advice to people for a healthy stomach?
A: Today, we spoke about a variety of stomach related problems. As a gastroenterologist it is not easy to give a specific advice to people, because it covers a wide range of issues. However, breaking it down to the very basics, I think my advice to people would be to have a healthy diet, increase intake of fruits and vegetables, restrict fat intake or have it in moderation, try to maintain weight, some exercise every day. These are things that will keep you in good health generally.
If you keep your weight at optimum level, it will take care of diabetes, blood pressure and so on. It may not help inflammatory diseases because those have a different pathway. But if you have normal weight, treating those diseases would be easier.
This is my general advice. I can give a more focused answer if it is about a specific disease.
Q: You said about increasing the intake of fruits and vegetables. But it’s a well known fact that vegetables and fruits these days come with harmful pesticides. How can we overcome that problem?
A: This is a question that is outside my expertise. But you have organic foods that are available at some places in Kuwait. But then they are very expensive. To feed a big population, you need chemicals. You need fertilizers and pesticides. These will in some way come down the supply chain. The concerned ministry in Kuwait is keen on where the food is coming from and so to some extent this chemical contamination of food is under check. But no bulk supply of food can do away with pesticides totally.
Q: Is it true that keeping vegetables and fruits soaked in turmeric water will remove pesticides from them?
A: I don’t know of any scientific study that says this. Having said that, turmeric does have a lot of medicinal properties and is widely being studied for use in medicine, I am not talking about traditional medical practices, but modern medicine. Turmeric or chemicals extracted from it are being investigated for possible benefits in Alzheimer’s disease, cancer, inflammatory disorders and other clinical disorders. According to a 2005 article in the Wall Street Journal, research activity into curcumin and turmeric is increasing. Some research shows compounds in turmeric to have anti-fungal and anti-bacterial properties.
So, this idea of keeping vegetables soaked in turmeric water might have some truth in it, but I am not aware of any scientific studies that back it.