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Westernisation of gastrointestinal diseases in Asia
  1. J J Y Sung
  1. Correspondence to:
    Professor J J Y Sung
    Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong;


Report on the Asia Pacific Congress of Gastroenterology Digestive Week, Singapore, 2003

  • gastro-oesophageal reflux disease
  • epidemiology
  • GORD, gastro-oesophageal reflux disease

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More than 1200 delegates from 29 countries attended the three day Asia Pacific Digestive Week (APDW) in Singapore. Full coverage of gastrointestinal and hepaticobiliary diseases was fashioned. It becomes increasing clear that with urbanisation and increasing affluence in many Asian-Pacific countries, and changes in lifestyle and eating habits, many diseases which used to be rare in this region have become prevalent in the past decades. Gastric cancer and gastrointestinal infections are on the decline. On the other hand, inflammatory bowel diseases, including ulcerative colitis and Crohn’s disease, are beginning to emerge. Non-alcoholic steatohepatitis, an indication of deranged metabolism and insulin resistance, has increased by up to 20-fold in some countries. Yet the two most important conditions discussed extensively at this conference were colorectal cancers and gastro-oesophageal reflux disease.


Colorectal cancer has become one of the most common malignant diseases in many Asia Pacific countries, and Australia, Japan, and New Zealand top the list for prevalence. In recent years, Hong Kong, Korea, and Singapore have witnessed a steady rise in incidence in both males and females. In a case control study from Japan, in which subjects over the age of 40 years were invited for yearly faecal occult blood testing using the immunochemical test, the risk of developing advanced cancer was significantly reduced among those who were screened within the past three years.1 A screening programme with immunochemical faecal occult blood testing appears to be effective for the prevention of advanced colorectal cancer, especially rectal cancers. On the other hand, flat or depressed adenomas, which were first described in Japan, are now more widely recognised as a distinct entity. A study from the UK revealed that among 321 adenomas, polypoid adenomas were found in 63%, flat adenomas in 36%, and depressed adenomas in 0.6%.2 Data also suggest that flat adenomas may have a higher risk of carrying high grade dysplasia (large flat adenomas 29%). Colonoscopy has been tested as a screening tool for colorectal cancer in an Asian population. In a prospective study conducted in Hong Kong, 505 healthy asymptomatic volunteers over the age of 50 years were offered colonoscopy. Advanced colonic lesions were found in 63 (12.5%) patients, and up to one third of these were located in the proximal colon.3 The incidence of these advanced colonic lesions is comparable with that of US studies. This study also confirmed the safety of the procedure. Despite the alarming increase in colorectal cancer incidence in Asia, in most countries there is still a lack of public awareness. It is clear that public education and awareness of the medical profession should be the next step. Governmental support to conduct epidemiological studies and screening programmes is very much in need.


It is generally agreed that gastro-oesophageal reflux disease (GORD) is a relatively uncommon condition in Asia. In the past few years, however, there has been a remarkable increase in the frequency of GORD in Asian countries such as Japan and Singapore.4 Unlike populations in the West, Asian patients are more likely to suffer from non-erosive than erosive GORD. Among those with oesophageal erosions, the majority have mild disease. Because of cultural and language differences, heartburn is seldom reported in Asian patients with GORD. On the other hand, non-cardiac chest pain is frequently found in patients with abnormal 24 hour pH monitoring.5

The Asian-Pacific Consensus Group reported their recommendation in APDW 2003.6 The Working Party examined the literature and concluded that while endoscopy is the gold standard for the diagnosis of erosive GORD, the diagnosis of non-erosive GORD would rely on a negative endoscopy and a positive oesophageal pH test or a positive therapeutic trial of proton pump inhibitors. Much controversy and debate have arisen from the relationship between Helicobacter pylori infection and the development of GORD. The Working Party concluded that the weight of evidence shows no correlation between H pylori infection and GORD. As long term proton pump inhibitor treatment in patients with H pylori infection accelerates atrophic gastritis, the Working Party proposes to check and treat H pylori infection before commencing on long term proton pump inhibitors. The Working Party also suggests on demand or intermittent therapy with standard doses of proton pump inhibitors for the treatment of non-erosive GORD. Family doctors are advised to use the proton pump inhibitor test as the first investigation for suspected GORD patients without alarming symptoms. Endoscopy should be offered when symptom persist or when alarming features develop.