TPW

INTERVIEW 51 As an eminent Gastroenterologist of the country, would you please let us know about the Gastrointestinal, Pancreaticobiliary and Liver diseases in our country? The diseases of Gastrointestinal (GI) system include the diseases from the mouth to the anus, hepatobiliary system and the pancreas. The most common diseases of the GI system in Bangladesh according to the site of involvement are as follows: a. Diseases of the oral cavity: Aphthous stomatitis, Nutritional deficiency oral ulcer, Oral candidiasis, Oral malignancies. b. Diseases of the oesophagus: Gastroesophageal reflux disease (GERD), Achalasia of the cardia, Carcinoma of oesophagus, Oesophageal candidiasis, Corrosive induced oesophageal stricture. c. Diseases of the stomach: Peptic ulcer disease, Non ulcer dyspepsia, Gastric neoplasms. d. Diseases of the intestine: Acute and chronic diarrhea, Intestinal tuberculosis, Ulcerative colitis and Crohn’s disease, Abdominal gas and bloating, Irritable bowel syndrome, Colonic malignancies. e. Diseases of the liver and biliary system: Acute viral hepatitis, Chronic viral hepatitis, Cirrhosis of liver, Liver abscess, Fatty liver disease, Liver malignancies, Cholelithiasis, Cholangiocarcinoma. f. Diseases of the pancreas: Acute and chronic pancreatitis, Pancreatic cancer. How common is GERD in our country? Can it lead to malignancy? How can we prevent such complications? Gastroesophageal reflux disease (GERD) occurs when acid from stomach reflux within the esophagus and causes heart burn, chest pain and regurgitation of food within mouth. Prevalence of GERD in Bangladesh is about 6% among adult population. The prevalence is more common among urban population, obese individual, females with multiparity and increasing age. Persistent acid reflux can cause irritation at lower esophagus and leads to the development of adenocarcinoma of esophagus. Prevention of GERD includes reduction of body weight if the patient is obese, elevation of head end of the bed during sleep, avoid smoking, heavy alcohol consumption, large evening meal, and high dietary fat intake, and avoid Non-steroidal Anti-inflammatory Drugs (NSAIDs). Medical treatment for GERD symptoms are, H2- receptor antagonist, proton pump inhibitors. Antacids particularly Sodium alginate containing antacids is more preferable. Sometimes higher doses of PPI are required and if the symptoms still persists the PPI plus antacid could be given. Those who are refractory to high dose PPI plus sodium alginate containing antacid, surgical treatment is the next option. As an alternative to medications and surgery several endoscopic techniques have been developed. Please tell us in brief about Peptic Ulcer Disease (PUD)? How do we treat and prevent recurrence of PUD? Peptic ulcers are sores that develop on the inside of the stomach, duodenum and lower end of esophagus. The most common causes of peptic ulcer disease are Helicobacter pylori (H pylori) infection and use of NSAIDs. Several medication therapies are available to reduce gastric acid secretion and healing of ulcer. Antacids neutralize gastric acid, H2 receptor blockers reduce gastric acid secretion by blocking gastric H2 receptors. Proton pump inhibitors (PPIs) are drugs that block the major pathways of acid production. If the ulcer is caused by H pylori infection, then anti- H pylori therapy is indicated. Ulcer recurrence is not uncommon particularly in those patients who take NSAIDs for relief of pain. If caused by NSAIDs then stop NSAIDs and use anti-ulcer therapy for healing of ulcer. If H. pylori are not cured after completing their first course a second treatment regimen is usually recommended in this case. What are the trigger factors and symptoms for Irritable Bowel Syndrome (IBS)? Is it preventable? What changes in diet can help the patients? The trigger factors for IBS symptoms are mainly diet which includes skin of fruits, certain vegetables like broccoli, cauliflower, Patients of IBS can minimize their symptoms by dietary modification, reduced anxiety and use of certain medication that may alleviate the symptoms Prof. Dr. Md. Ashraful Islam Consultant, Gastroenterologist Labaid Specialized Hospital Former-Head, Dept. of Gastroenterology, DMCH

53 cabbage, chickpeas, lentils and black beans. Also includes alcohol, chocolate, caffeine, carbonated beverages, fatty meal and dairy products. Other trigger factors are mental anxiety, use of antibiotics and following acute gastroenteritis. IBS is not curable but controllable. Patients of IBS can minimize their symptoms by dietary modification, reduced anxiety and use of certain medication that may alleviate the symptoms. Mainly there are three types of IBS. The subtypes are IBS-D which is diarrhea predominant, IBS-C constipation predominant and IBS-M mixed type of diarrhea and constipation. For IBS-D avoid the food which trigger the symptoms and for IBS-C advised for use of food which increase stool bulk and keep the stool soft with adequate amount of water. What are the risk factors of developing Non-Alcoholic Fatty Liver Disease (NAFLD)? How often can NAFLD progress to Nonalcoholic Steatohepatitis (NASH)? What can be done to prevent it? Nonalcoholic fatty liver disease (NAFLD) is a condition of the liver when there is excess accumulation of fat within the liver and who does not intake alcohol. It is more prevalent in western countries but gradually increasing in Bangladesh. The risk factors for developing NAFLD are genetic factor, sedentary life style, overweight or obesity, type-2 diabetes mellitus, insulin resistance, high blood cholesterol and hypothyroidism. Cirrhosis of liver is the main complication of NAFLD and NASH. NASH is a condition when there is inflammation of the liver caused by fatty liver disease and this NASH can progress to cirrhosis of liver. In USA it is estimated, that about 25 percent of adults have NAFLD and that NAFLD have 25% NASH. However, NAFLD is a preventable disease. Advise for life style modification, dietary restriction like avoiding fatty meal and simple carbohydrates, correction of blood cholesterol, control of DM, correction of body weight and regular exercise. Why Hepatitis B vaccine is not being prescribed to all patients, considering its availability and high risk of chronic infection leading to cirrhosis and liver cancer posed by Hepatitis B virus infections? Hepatitis B virus infection is the leading cause of cirrhosis of liver in Bangladesh. A previous study reported that the prevalence of hepatitis B virus in Bangladesh is 5.4% in general population. So, every individual should be vaccinated for prevention of hepatitis B virus infection. The government of Bangladesh has included Hepatitis B vaccine in Expanded Program on Immunization (EPI) since ’23 but not extended to adults. So every adult should be vaccinated after checking their hepatitis B virus status. l Abdominal Wall Hernia: A painful condition that happens when part of your digestive system pokes through an opening in your abdominal muscles. Alimentary Canal: Another name for the entire digestive tract. Barrett’s Oesophagus: A condition that can occur after long term acid reflux when the cells lining your oesophagus change. Bloating: An uncomfortably full or swollen feeling in your abdomen. Colonoscopy: An investigation using a camera on a flexible tube to examine your large intestine. Diarrhea: Loose, watery stools often combined with increased frequency of bowel movements. Endoscopy: An investigation using a camera on a flexible tube to examine your digestive tract. Endoscopic Resection: A procedure conducted alongside endoscopy to remove a tumor or other abnormal tissue from your digestive tract. Gallbladder: A small organ that stores the bile produced by your liver and releases it into your gut to help digest fats. Gastroscopy: An investigation using a camera on a flexible tube to examine your throat, stomach or small intestine. GORD or Gastro-Oesophageal Reflux Disease: A condition that occurs when stomach acid frequently rises into your throat, causing pain and discomfort. Indigestion, Heartburn or Acid Reflux: A common symptom caused by stomach acid rising into your throat, often after overeating. Can be a sign of a more serious condition such as a peptic ulcer or GORD. IBD or Inflammatory Bowel Disease: A general name for conditions like ulcerative colitis and Crohn’s disease that cause inflammation in the gut. IBS or Irritable Bowel Syndrome: A long term condition that can make you sensitive to certain foods. Symptoms include constipation, diarrhea, and abdominal cramps. Liver Function Test: A blood test that can help identify problems with your liver or gallbladder by measuring the levels of certain enzymes and proteins. Oesophagus: A medical term for the part of your throat leading from your mouth to the stomach. Not to be confused with the trachea or windpipe, which goes to your lungs. Oesophageal Manometry: A test to check the strength of the valve that prevents acid escaping from your stomach into your oesophagus. Oesophageal Stent: An implant that can open narrowed sections of the oesophagus. Ulcerative colitis: A form of inflammatory bowel disease that causes ulcers and inflammation in the inner lining of the colon and rectum. Watermelon Stomach Laser Treatment: Laser treatment to stop bleeding caused by dilated blood vessels in your stomach. Upper GI series: X-rays of the esophagus, stomach, and duodenum. Villi: Tiny finger-like projections on the surface of the small intestine that help absorb nutrients. l GLOSSARY OF TERMS INTERVIEW

INTERVIEW 55 As an eminent Gastroenterologist of the country, would you please let us know about the common pancreatobiliary and oncologic disorders of the gastrointestinal (GI) tract in our country? In Bangladesh, like many other countries of the world, among the pancreato-biliary diseases, stone diseases predominate over others in incidence and prevalence. Among them, cholelithiasis or gallbladder stone is found in most of the cases, stones may also be found in the common bile (choledocholithiasis), in the cystic duct and in the hepatic ducts. Other disease which affects the biliary tracts is cholangitis. Some immunological diseases in the form of primary biliary cholangitis and primary sclerosing cholangitis are also encountered in practice. Cystic diseases (e.g. choledochal cyst) are rarely found. Pancreatic diseases are mostly acute and chronic pancreatitis. Cystic diseases of pancreatic are also not very uncommon. Malignant diseases affecting pancreato-biliary tracts are carcinoma gallbladder, cholangiocarcinoma, periampullary carcinoma and also solid and cystic carcinomas of pancreas. Oncologic disorders, if we start from the upper part of the GI tract, carcinomas of the esophagus are not very uncommon in our country. These may be in the form of squamous cell carcinoma or adenocarcinoma depending on whether it is present in the upper or lower part of the oesophagus. Carcinoma of stomach is one of the common malignancies not only of gastrointestinal tract but also of the whole body. Other cancers which are found in stomach are lymphoma and malignant neuroendocrine cancer. MALT lymphoma, a special variety of Helicobacter pylori related malignant disease is also found on occasions. Malignant diseases affecting the small gut are rare, but adenocarcinoma and lymphoma are sometimes encountered. Carcinoma of colon is another common malignancy of gastrointestinal tract but also of all malignancies. Carcinoma of anal canal is sporadically seen. What are the trigger factors and symptoms for Irritable Bowel Syndrome (IBS)? Is it preventable? What changes in diet can help the patients? We know, IBS occurs spontaneously, however, there are some factors which can stimulate the symptoms to develop or to flare. These may be in the form of physical or psychological trauma. Mental trauma in any form, either on personal, social or professional life, may trigger IBS symptoms to develop in all types of IBS. Nonetheless, the diarrheal type IBS is more affected by any form of stress factors. Some types of food and GI infections can also trigger the symptoms. IBS is probably not totally preventable. But the symptoms can be minimized by avoiding the triggering factors. If we can maintain the habits of taking good food, the chance of GI infection and inflammation will be reduced and IBS symptoms are also expected not to occur or to improve. Although there is no universal diet recommended for IBS, but generally, if the patients can identify a particular food that aggravate the symptoms, should better be avoided. By avoiding fatty and fried foods, most of the IBS patients enjoy better quality of life. Wheat products may aggravate IBS symptoms in some patients and are advised to avoid them. Lactose intolerance can be concomitantly present in IBS patients, and may compound the IBS symptoms. So, milk and milk products should be avoided by these groups of patients. FODMAP (fermentable oligosaccharides, monosaccharide, disaccharides and polyols) diet should be reduced and Mediterranean diet may also be followed. Please tell us in brief about Peptic Ulcer Disease (PUD)? How common is H. Pylori infection in our country? How do we treat it and prevent recurrence? Peptic Ulcer Disease (PUD) is the ulcers formed in any part of the gastrointestinal tract, due to the breach of continuity of their inner linings (mucosa) by acid-pepsin digestion. Commonly the stomach or the duodenum is the sites of Peptic Ulcers Disease (PUD). Peptic Ulcer Disease (PUD) is common all around the world as in Bangladesh. A study done in the early 80’s found that around 16% of adult people in our country suffer from Peptic Ulcer Disease (PUD). With the improvement of socio-cultural and economic standard and change of food processing and taking, the prevalence of PUD is decreasing over time. In recent studies, these infection have been found prevalent among 5-8% of the populations. Helicobacter Pylori is the Helicobacter Pylori is the leading cause of PUD worldwide and also in Bangladesh Prof. Dr. A H M Rowshon Professor Department of Gastroenterology BIRDEM General Hospital, Dhaka

57 leading cause of PUD worldwide and also in Bangladesh. In the 90’s, a number of studies showed that more than 90% of our adult population had been infected with H. Pylori and almost all of the patients of PUD were found H. pylori positive. Awareness is being developed and treatments were given since then. More recent studies have shown that, the prevalence of Helicobacter Pylori is around 70-80%. Although the prevalence of both H. pylori and PUD has reduced, it is still very high, especially in the elderly population. Mostly, we treat Helicobacter Pylori with combination of antibiotics and an acid suppressing agent, commonly known as triple therapy and quadruple therapy. Clarithromycin is the common denominator in most of the regimens for the treatments of Helicobacter Pylori related PUD, because, all the studies done in our country have showed that the resistance of Helicobacter Pylori to clarithromycin is less than 15%. Being available over-the counter, patients now-a-days are selfprescribing and overusing antiulcerant drugs i.e. PPIs. What are the consequences of such irrational use? It may seem to be irrational, but is logical, because of very high prevalence of PUD all over the world, every patient of Peptic Ulcer Disease (PUD) cannot consult with the gastroenterologists or physicians. On the other hand, because of simple oral route of administration and relatively wide safety profile especially for short term use, PPI’s are made over-the-counter drugs all over the world, not only in Bangladesh. Initially, parietal cell tumors of stomach were found in animal studies, but no such record was found in human studies. However, recently, it has been reported that, when used for long period of time, PPIs may cause recurrent of GI infection and diarrhea. Some people are shown to have developed early osteoporosis with bone fractures, especially hip bone. Many patients also have reported to develop pneumonia. Interstitial nephritis is another complication of long-term PPI use. Hypomagnesaemia has recently been recognized as a side effect of PPIs. So, PPIs, apparently considered safe, should no longer be considered as safe especially for long term indiscriminate use. Please tell us in brief about Endoscopic Retrograde Cholangiopancreatography (ERCP). For which conditions can ERCP be used? ERCP is a procedure through which we can diagnose many pancreato-biliary diseases and also offer treatment for many of the diseases over there. However, nowadays it is almost never used for diagnostic purpose, as nowadays, we have Magnetic Resonance Cholangiopancreatography (MRCP) which is a non-invasive procedure providing almost similar diagnostic results. ERCP is rather used for therapeutic purposes in removal of stones from the biliary tree and the pancreatic tree, removal of polyp especially when it is around the ampulla. Worms from the biliary can also be removed through ERCP. ERCP is used as palliation maneuver for biliary and pancreatic drainage by placing stents in obstructive diseases in conditions like cholangiocarcinoma, stricture, stenosis, unusually large stones and fibrosis of chronic pancreatitis. Where does Bangladesh stand as far as prevention, diagnosis and treatment of GI diseases are concerned, compared to the advanced countries? Bangladesh is a developing country, with rapidly developing healthcare facilities. With improvement of the economic status, we are improving our status of hygiene. We are progressing in prevention and treatment, especially of communicable diseases by ensuring safe water supply to most of the people. Proper disposal of human excreta is also almost completely achieved. Most of the infective diseases are early diagnosed and appropriately treated. Many of them are also through our national mass vaccination program. Our healthcare professionals are also maintaining proper precautions and antiseptic measures during giving treatment and surgical procedures. Regarding the non-communicable diseases, awareness is also being built up among our people. People are better educated about diabetes, hypertension, liver or kidney diseases and opting for a healthy lifestyle. We are hopeful that our healthcare would reach the standard of the advanced countries very soon. l What does a gastroenterologist do? A gastroenterologist is a specialist with expertise in the disorders and diseases that affect the digestive system — which includes the gastrointestinal tract (esophagus, stomach, small intestine, large intestine, rectum and anus) as well as the pancreas, liver, bile ducts and gallbladder. The digestive disorders and issues that a gastroenterologist treats include: Unexplained changes in bowel habits, including diarrhea, constipation and blood in the stool, Gastroesophageal reflux disease (GERD), Heartburn, Hemorrhoids, Inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis, Irritable bowel syndrome (IBS), Pancreatitis, Ulcers. Gastroenterologists are trained to perform a number of procedures used to help diagnose and treat conditions, such as: Upper endoscopy, Colonoscopy, Biopsy and the various Endoscopic techniques needed to visualize the digestive system, including Endoscopic Ultrasound. Knowing Your Liver: The liver is the largest internal organ inside the human body. Its job is to store necessary nutrients which have been absorbed in the intestines and put them to good use by metabolizing them for energy or repairing various organs. Symptoms Of Liver Cancer: Early-stage liver cancer tends to be silent. However, as the cancer grows, patients may experience: Fatigue, Loss of appetite, Weight loss, Indigestion, Pain around the lower right rib, Heartburn, Radiating pain to the right shoulder or under the right shoulder blade. Types of Liver Cancer: Cholangiocarcinoma & Hepatocellular Carcinoma Liver cancer is preventable: if the patient receives screening or surveillance. Early detection leads to higher chance of a cure. Patients should choose a hospital that has multidisciplinary team of specialists for the best treatment outcome so that they can return to their normal lives. l FACTS ON FINGER TIPS INTERVIEW

INTERVIEW 59 As an eminent Hepatologist of the country, would you please let us know about the liver diseases in our country? If you talk about the liver diseases in Bangladesh, we see a vast number of liver diseases since hepatology is a big subject. But if we narrow it down on the disease that we see commonly in our practice, one is Hepatitis B and next is Fatty Liver and the third one is Hepatitis C. These are the major causes of all major forms of liver diseases in the country, including chronic hepatitis, liver cirrhosis and primary liver cancers. Hepatitis B is the leading cause followed by fatty liver and hepatitis C virus these days. Apart from that we also see a good number of patients who come with jaundice or acute hepatitis and those are caused mainly by hepatitis A and E viruses. We also get a good number of patients, who get drug induce liver injuries, due to malpractice of herbal medicines. I’m not at all against herbal medicines, but you know, the people prescribing herbal medicines without any scientific basis can cause liver diseases as we see in our practice every day. Please tell us, in brief, about the prevalence of Viral Hepatitis in Bangladesh. What can be done to eliminate Hepatitis B from the country? As I was telling, hepatitis B is the leading cause of all chronic liver diseases in Bangladesh. About 60 percent of liver cirrhosis and 60 to 70 percent of liver cancers in Bangladesh, results from hepatitis B virus. Around 10 to 15 percent of liver cirrhosis and liver cancers result from fatty liver followed by hepatitis C virus. Elimination of hepatitis B is a priority for Bangladesh because the sustainable development goal target 3.3 tells us that we have to eliminate hepatitis B and C from the country, as is followed by all countries of the world that we have to eliminate these from the world as well. Our government is carrying out a very effective vaccination program for the last seventeen years and we have very successfully brought down the prevalence of hepatitis B in Bangladesh to less than 1 percent in our less then five years old population. However in adults, who are more than seventeen years of age, it is still a big problem. So, if we want to eliminate hepatitis B, since most patients are unaware of their illness, first of all, we must make people aware that hepatitis B is a disease, they should get tested and vaccinated and those who test positive should get treated. Next matter of fact is that, when we will make people aware they will seek treatment. So, we have to increase the number of Hepatologists in the country because if suddenly, there is a surge of patients with hepatitis B, we don’t have enough Hepatologists. Next issue is providing treatment, if we want to provide treatment we need to have drugs. We have pretty good drugs, but the drugs are still expensive if you compare to India. Some other drugs are 3/4 times or even 10 times more expensive, I don’t say that we have to be at par with India in terms of COD. India produces API (Active Pharmacy Ingredients) and we don’t, so our drugs will obviously be expensive as we import the raw materials. But still then, the drugs can be twice more expensive than India, but it cannot be 3 /4 times or 10 times more expensive. So, this is another matter we have to concentrate on. Finally, we have to build infrastructure for treating such patients. We have one National Gastro-Liver Institute in the country, but as we all know that, we have one Cancer Institute, we have one Kidney Institute, and one Burn Institute. However, the government realizing the fact is now constructing especially centers in eight divisional cities for treating cardiac cases, cancers, traumas, accidents etc. So like that, I don’t say that we have to make another National Institute in Dhaka for liver disease management, but outside Dhaka in the greatest cities like Chattogram, Syhlet, Rajshahi, Khulna, etc. We have to start constructing liver disease centers as well. We are very happy that under the current government we have spent a huge amount for our infrastructural development. However, we don’t need to make another Padma bridge or maybe one more Padma bridge, maybe we need to make one more atomic reactor. But after 10 years, this development I think hepatitis B vaccine should be on our priority list and the government should actively consider introducing adult or catch-up vaccination Prof. Dr. Mamun-Al-Mahtab (Shwapnil) Division Head Interventional Hepatology Division Dept. of Hepatology BSMMU

need will slow down and we will be utilizing our resources for further upliftment and sustainability of development. At that point of time, if we suddenly see that we have 3million liver cancer patients, liver cirrhosis patients, and so many patients with liver diseases, that will add an unexpected burden to the country. We can make a Padma bridge in 10 years but we cannot produce Liver Disease Institute and Specialized Hospitals and skilled manpower in such a short time. So it’s the right time now that we start preparing in order to face the next challenges that the country is going to face. So elimination of hepatitis B is a big spectrum and we should concentrate from now on. Why Hepatitis B vaccine is not being prescribed to all patients, considering its availability and high risk of chronic infection leading to cirrhosis and liver cancer posed by Hepatitis B virus infections? This is a very pertinent question, many countries of the world have introduced catchup or adult vaccination. I’m sure you have seen the recent World Health Organisation (WHO) report, that Bangladesh is 7th among the top 10 hepatitis B and C infected countries. The World Health Organisation (WHO) has clearly stated that Bangladesh is one of the high risk countries for hepatitis B and C. One of the best ways of getting rid of hepatitis B is vaccination. So, I think it’s very important now that we encourage our adult population to get themselves vaccinated. But at the same time, government should also come forward for adult catch-up vaccination where people who are adults who missed the childhood vaccination be given vaccines by the government at this stage. The government started this project where healthcare professionals are being vaccinated first, and subsequently should be extended to general population as well and I think the country should be producing more vaccines. At present only 2 or 3 companies of the country are producing vaccines. We know that our Honourable Prime Minister has taken initiative to make a big vaccine plant. I think hepatitis B vaccine should be on our priority list and the government should actively consider introducing adult or catch-up vaccination. As the principal investigator in the clinical trials on NASVAC, would you please tell us about this novel generic for chronic hepatitis B? NASVAC is a drug that is an immune therapy and is a very new concept. We have very good drugs for hepatitis B, but you have to give those drugs for 10, 20 or even 15 years and in some cases life-long and you know, even though if a patient is very compliant, taking the drugs regularly, we still cannot ensure that we you can prevent liver cirrhosis or liver cancers in such patients. Despite taking drugs regularly, many of them can develop such diseases and also you can easily understand a patient does not want to take a drug for 10-20 years or lifelong. So, the Holy Grail would be a drug for hepatitis B that we can prescribe for a few weeks or a few months, and the patients can also relax knowing that they don’t need to go to their Hepatologist for such long years and their liver will be okay. NASVAC is the first immune therapy against any chronic infection not only hepatitis B, that has crossed phase-3. We have now published our 5 years follow-up data and 10 years data is going to be published soon. We have seen patients in the phase-3 clinical trial, that we did in Bangladesh, did not develop liver cirrhosis or liver cancer, which is a very interesting thing. This is not something I’m telling you for the media only. This is something that I’m telling you on the basis of scientific publications, top class medical journals. So, NASVAC is a drug you give for six months as an immune therapeutic agent without any adverse events and it will protect the liver as we have seen in our experience. Our Japanese colleagues who have done a clinical trial in Japan also showed that they have found a significant number of patients become HBs AG negative with NASVAC. As per the current status of NASVAC, our drug control committee has approved the recipe of NASVAC. We are expecting that the commercial registration will be done very soon and we are very hopeful that the local pharmaceutical company called Beacon Pharmaceuticals Limited will introduce NASVAC to our market within this year. But unfortunately, we will not be the first country to introduce NASVAC as I have been to Cuba recently where I was given the highest scientific award of the Cuban government by a decree of the President of Cuba. It’s called the Carlos J. Finlay for Science. During my recent visit to Cuba I visited at least two hospitals, including their National Gastroenterology Institute, where they are prescribing NASVAC as the first line of treatment for hepatitis B. I was very fascinated to see that people from different countries of the world like China, they are now flying to Cuba to get NASVAC. So hopefully, when NASVAC comes to Bangladesh, it will be a pride for Bangladesh because the first drug that was developed in Bangladesh, getting registered and commercialized in Bangladesh will not only help the people of Bangladesh, but it will create enormous opportunities where we will see patients from abroad coming to Bangladesh to take NASVAC. What is Non-Alcoholic Steatohepatitis (NASH)? How do we prevent and treat NASH? There are many patients or individuals who do an ultrasound test and find that they have fatty liver, especially in a country like Bangladesh, who have rice, a carbohydrate staple diet. Fatty liver not necessary will cause liver disease, but many patients with fatty liver will have chronic hepatitis, that is long-term chronic inflammation of the liver persisting for more than six months. These patients who have fatty liver induced chronic hepatitis, we call it Nash or Non-Alcoholic Steatohepatitis. These Nash patients are at risk of developing liver cirrhosis and liver cancer. As I was telling in the early part of my interview, that nowadays we see Nash as the second most important cause of liver cirrhosis and liver cancer in Bangladesh, after hepatitis B and that is not something that we see in Bangladesh only, this is a global phenomenon. Right now we are facing, not an endemic rather a pandemic of NASH and this will be increasing only because, with our improvement of lifestyle, improvement of food habit, we are only expecting more Nash patients to come up in the coming years. So, it is a very important health issue and I believe that the government will take up a program under the non-communicable disease control division of the Directorate General of Health Services (DGHS) to control Nash. Already India has introduced a Nash control program in their National program. So, it’s something that I think is very important for Bangladesh to do as well. One more important factor for Nash is that people who have diabetics develop Nash very easily. India is a topmost country of the world in terms of type 2 diabetes and we are on the top 10 list, so we are at no less risk. NASH is therefore an important concern. One more thing about NASH is the fat that accumulates in the liver, can accumulate in the heart, brain and increase the risk of cancer too. So, unlike hepatitis B and C patients, who die from liver cirrhosis or liver cancer in many cases, NASH patients may have a good liver but die from cardiac 60 INTERVIEW

INTERVIEW 61 diseases, heart attacks, strokes, cancers. So it’s very important that we start considering Nash with due importance from now. What is the role of Plasma exchange (PLEX) in Acute on Chronic Liver Failure (ACLF)? What can be done to reduce the mortality rate in ACLF? ACLF is a new disease entity, which has been under discussion for about 10 years now. There are group of patients with chronic liver disease, who suddenly develop liver failure. It is very common in Bangladesh, for example, due to hepatitis B, irrational use of herbal medicines and many other reasons like, infections, drugs etc. So ACLF is common in Bangladesh, ACLF has a mortality of 30 to 40 percent. That is patients, who develop ACLF die in 30 to 40 percent cases. The only curative option for ACLF so far is liver transplantation. Unfortunately, we don’t have liver transplant program as an option in the country and we can never have enough liver transplants in the country ever. This is not that I am skeptical, this is a reality. For example, India is the 3rd largest nation in terms of liver transplantation and they do around 2500 to 3000 liver transplants every year and there are 75 liver transplantation centers in India at least. Many Bangladeshis go and get liver transplants in India, but the fact is India needs to do at least 25 to 30 000 liver transplants a year. So, being a leader in liver transplantation they cannot meet their own demand. From there, I can tell you that we will not be able to meet our own demand too. So, we always should look for cheaper and better options, if not better, at least useful options to treat ACLF. Plasma exchange which is a very good treatment modality, where you exchange the plasma of the patient. In many cases it can prevent deaths from ACLF, can prevent liver transplants. We are doing plasma exchange in Bangladesh for last 4 years. In fact, during Mujib Borsho, we collaborated with Christian Medical College (CMC), Vellore, who are one of the leaders in plasma exchange in the region. I was then the chairman of liver department of BSMMU. We introduced plasma exchange in BSMMU as part of our Mujib Borsho celebration program and I’m very proud to say that we have published so far, two international publications on our plasma exchange experience. We call it Mujib protocol which was introduced in our department during Mujib Borsho, and the first scientific paper on plasma exchange that was published in Bangladesh also says Mujib Protocol. So, Mujib protocol is now a part of scientific literature. l DID YOU KNOW? Water serves as a building block in all of our body’s cells, as well as in the many tissues and compartments. Due to its high heat capacity, water aids in thermo regulation by reducing body temperature fluctuations in warm or cold environments. It acts as a carrier in the human body and aids in the transportation of nutrients to the cells. Acute fatty liver of pregnancy (AFLP) is a dangerous condition of late pregnancy. Once diagnosed, or even suspected with a high degree of likelihood, it must be treated in a timely manner to ensure a good outcome. About three in every four cases will be delivered by Cesarean section within 48 hours of the diagnosis being made, but a few may have their pregnancy prolonged by up to 2 weeks. Vitamins and supplements for ulcerative colitis Vitamins and supplements may help boost nutrient levels when diet alone is not enough. Certain foods can trigger symptoms of UC, and many people with the condition find that dietary modifications can help provide relief. Some people also take vitamins and supplements to avoid flares or adjust to dietary changes that help relieve symptoms. People with UC may be prone to certain vitamin deficiencies due to inflammation in the gut and reduced intake caused by reduced appetite and the avoidance of digestive issues. Iron deficiency, with or without anemia, is a common issue in people with IBDs such as UC, affecting up to three-quarters of people with newly diagnosed IBD. Low iron levels are often the result of reduced intake and blood loss caused by inflammation and damage to the digestive tract. This is more common during flares. People with UC may also experience vitamin Ddeficiency. The main sources of vitamin D are dairy foods and sunlight. Some people with UC are sensitive to dairy foods and may limit their intake to avoid digestive issues. This can lead to calcium deficiencies. Sunlight can help process vitamin D in the body, but this can also be an issue for people with UC. “People who are medically treated for UC may need to take particular care in the sun because several medicines can cause photosensitivity, which is an exceptionally high sensitivity to the UV waves in sunlight. Diabetes drug slows Parkinson’s disease A diabetes drug called lixisenatide has shown promise in slowing the progression of Parkinson’s disease. Lixisenatide is in the family of GLP-1 receptor agonists, such as Ozempic, that have made headlines as weight-loss drugs. In the latest clinical trial, lixisenatide was given to people with mild to moderate Parkinson’s who were already receiving a standard treatment for the condition. After a year they saw no worsening of their symptoms, unlike a control group whose condition did worsen. Further work is needed to reduce the drug’s side effects, such as nausea and vomiting, and to determine whether its benefits last.

INTERVIEW 63 Trigger factors of IBS are Diet, Bacterial Infection & Anxiety Prof. Dr. Swapan Chandra Dhar Professor of Gastroenterology Lab Aid Specialized Hospital Dhaka d. Large Gut - IBS, IBD, TB, Lymphoma, Malignancy, Anal Fissure, Hemorrhoids, Rectal Ulcer (Infective), SRUS, Diverticulitis. What are the trigger factors and symptoms for Irritable Bowel Syndrome (IBS)? Is it preventable? What changes in diet can help the patients? Trigger factors of IBS are: i. Diet - Milk and Milk Products, Spicy and Oily Food, Street Food / Junk Food, Leafy Vegetables. (ii) Infection - Bacterial. (iii) Anxiety Symptom of IBS includes: i. Diarrheal Type (IBS-D)- Frequent loose motion, Cramping abdominal pain relieved by defecation, Sense of incomplete defecation, Gas, Flatulence. ii. Constipation Type (IBS-C) - Constipation, Pain Lower abdomen/per umbilical, relieved by defecation. iii. IBS Mixed (IBS-M) - Alternate Constipation and Diarrhea. iv. Indeterminate Type – Symptoms do not correlate with the above three categories. Is it Preventable? One set of disease is not preventable but symptoms can be prevented or relieved to some extent by avoiding the trigger factors. What changes in diet can help the patients? Common diets those aggravate the symptoms such as: milk and milk products, leafy vegetables, street foods, junk foods, high spicy foods, etc. These should be avoided if any other food creates problem to somebody, those should also be avoided. Please tell us in brief about Peptic Ulcer Disease (PUD)? How do we treat and prevent recurrence of PUD? Peptic Ulcer Disease means ulcer in the stomach & first part of duodenum due to increase acid & pepsin secretion. Treatment is done with any one of PPI like Omeprazole, Esomeprazole, Lansoprazole, Rabeprazole, Pantoprazole, Deslansoprazole or Potassium competitive acid blocker like Vonoprazan. Prevention of recurrence of PUD By Anti H. Pylori Therapy: (Triple Therapy) i. PPI 20mg twice day/Vonoprazoan 20mg once daily for 2 weeks. ii. Amoxicillin 1gm twice daily 2 weeks. iii. Clarithromycin 500mg twice daily for 2 weeks / Levofloxacin 500mg daily for 2 weeks. Quadruple Therapy - If Triple Therapy Fails. How common is GERD in our country? Can it lead to malignancy? How can we prevent such complications? Although there is no sufficient data about the prevalent of GERD in our country in one study the prevalent among rural population was 6.5%. The prevalence is gradually increasing. Can it lead to Malignancy? Yes, it can lead to Malignancy in the lower end of Esophagus. How can we prevent the complications? Complications can be prevented by early diagnosis and proper management of the disease. Why Hepatitis B vaccine is not being prescribed to all patients, considering its availability and high risk of chronic infection leading to cirrhosis and liver cancer posed by Hepatitis B virus infections? Hepatitis B Virus vaccine should be prescribed to all unvaccinated people. Many physicians particularly Gastroenterologists and Hepatologists prescribe HBV vaccine to unvaccinated people. All physicians should prescribe HBV vaccine to unaccented people attending their chamber. Awareness of the physician is also important. What are the risk factors of developing Non-Alcoholic Fatty Liver Disease (NAFLD)? How often can NAFLD progress to Nonalcoholic Steatohepatitis (NASH)? What can be done to prevent it? Risk factors are - Obesity, Sedentary life style, Diabetes mellitus, Metabolic Syndrome, DLP, Hypertension, Hypothyroidism, Growth Hormone Deficiency and Genetic. Prevention of NASH/NAFLD - Treatment of obesity and other diseases that leads to NAFLD, changing life style, daily walking, taking balanced diet (less carbohydrate and fat), avoiding junk food /rich food. l As an eminent Gastroenterologist of the country, would you please let us know about the Gastrointestinal, Pancreaticobiliary and Liver diseases in our country? Gastrointestinal diseases are: a. Diseases of Esophagus l Esophagitis - GERD, Eosinophilia Esophagitis, Corrosive Esophagitis, Radiation Esophagitis. l Esophageal Ulcer – Drug, GRRD, Corrosive, Foreign body impaction, Radiation. l Esophageal Cancer l Stricture Esophagus l Functional Disorder – Globus, Motility disorder, Dysphagia l Achalasia Cardia l Esophageal Polyp b. Diseases of Stomach - Gastric Ulcer, Carcinoma/GIST, NSAID Induced Ulcer, Motility Disorder, Gastro-paresis, Non Ulcer dyspepsia, Gastric Polyp. Rare diseases - TB, Crohn’s Disease, Lymphoma. c. Disease of Small Gut - Duodenal Ulcer, Carcinoma/GIST , NSAID Induced Ulcer, Polyp, SIBO, Tropical Sprue, TB, Crohn’s Disease, Lymphoma.

INTERVIEW 65 diarrhoea, dysentery, bloody diarrhoea and other GI infections. Jaundice of various types like A and E are commonly prevalent. Peptic ulcer disease and irritable bowel syndrome are common problems in the western world, though our people frequently encounter this problem. Liver abscess and round worm (ascariasis) in the common bile duct are common as well. These are the common gastrointestinal and liver diseases in our country. These are few examples of common GI problems we frequently encounter in our daily practice. Most common pancreatic disorder is acute pancreatitis and its complications. In western world it is mainly due to alcoholism. But, since rice is our staple food, blood TG level is high in our population. High triglyceride is one of the major causes of acute pancreatitis in our country. Most cases resolve spontaneously but, certain percentages have some deadly complications with high mortality rate. Repeated attacks of acute pancreatitis lead to chronic pancreatitis. Recently, there was another variant of chronic pancreatitis known as FCCP (Fibro Calcific Chronic Pancreatitis). It was mostly due to malnutrition. Chronic pancreatitis may present with deficiency of pancreatic enzymes leading to malabsorption syndrome and diabetes mellitus. Diseases of the biliary tree are congenital anomalies (choledocal cyst, caroli’s disease and bile duct stricture). Stone in the gallbladder and bile duct is a very common disorder. Strictures of the bile duct are due to surgery and inflammatory (stone induced) causes are also commonly encountered. Gastrointestinal tract starts from mouth and extends up to the anal orifice. It has some associated organs like liver, pancreas, gallbladder and bile duct. All these organs lead to multiple cancers. Most common cancer of the GI tract is the cancer of the stomach. It is the second most common cancer in the body next to lung cancer in male. Others are colorectal cancer (large bowel and rectum), oesophageal carcinoma, duodenal adenocarcinoma (duodenum), hepatocellular carcinoma, pancreatic carcinoma, gallbladder carcinoma and chloangicarcinoma (bile duct). All these cancers are frequently found in our daily practices. What are the trigger factors and symptoms of Irritable Bowel Syndrome (IBS)? Is it preventable? What changes of diet can help patients with IBS? Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits due to an altered interaction of the brain-gut axis, in the absence of any organic cause. Trigger factors of IBS1. Dietary triggers- i) For diarrhea predominant IBS, trigger factors are high fiber diet, chocolate, alcohol, caffeine, fructose, or sorbitol, carbonated drinks, fried and fatty foods, dairy products, especially if lactose intolerant and wheat for people who are allergic to gluten. ii) For constipation predominant IBS, trigger factors include, breads and cereals made with refined grains, processed foods (ex. chips and cookies), coffee, carbonated drinks, alcohol, high-protein diets, dairy products, especially cheese. 2. Psychological trigger factors – anxiety, stress, depression. 3. Menstruation. 4. Medication- Drugs that can trigger IBS include, antibiotics (due to alteration of the gut micro-biota), Anti-depressants (selective), Sorbitol containing drugs (ex- cough syrup). 5. Acute infection – post infectious IBS. 6. Poor eating habits – Such as chewing too quickly, eating large meals etc. 7. Chewing gum. 8. Sedentary lifestyle. 9. Genetic predisposition. Symptoms of irritable bowel syndrome1. Chronic abdominal pain — Described as a cramping sensation with variable intensity and periodic exacerbations. Location and character of the pain can vary widely. Severity of the pain may range from mild to severe. Pain is frequently related to defecation. In some patients abdominal pain is relieved with defecation, some patients report worsening of pain with defecation. Health professionals in our country are continuously managing the health hazards with utmost sincerity and devotion Prof. Dr. Md. Anwarul Kabir Professor & Former Chairman Dept. of Gastroenterology BSMMU, Dhaka As an eminent Gastroenterologist of the country, would you please tell us about the gastrointestinal, pancreatobiliary and liver disease in our country? Bangladesh is a tropical country. We have a primitive sanitation system. There is no supply of safe drinking water. We have no knowledge about the food hygiene and sanitation. Both the restaurant staffs and its customers are unaware of food sanitation, preservation, and safe delivery of food. It makes us prone to waterborne and food borne diseases throughout the year like

66 INTERVIEW 2. Emotional stress and meals may exacerbate the pain. 3. Abdominal bloating. 4. Increased gas production in the form of flatulence or belching. 5. Alteration of bowel habit-i) Diarrhoea: Frequent loose stools of small to moderate volume which may occur during waking hours, most often in the morning or after meals. May be associated with mucous discharge. No nocturnal episodes. Most bowel movements are preceded by lower abdominal cramping pain, urgency, and a sensation of incomplete evacuation. ii) Constipation- Less than 3 bowel movements per week which may be associated with straining. Hard and pellet shaped stools. May have sense of incomplete evacuation. May be associated with anorectal blockage requiring manual maneuvers. Is irritable bowel syndrome preventable? Although IBS is not a preventable disease, certain dietary and lifestyle modifications along with adjunctive therapies can help to control the disease symptoms to a great extent. Dietary modifications in IBS patients – A careful and meticulous history should be taken regarding the symptom pattern related to specific foods. Care must be taken to avoid those food groups particularly. 1. Exclusion of gas producing foods- Patients with IBS should be advised to exclude foods that increase flatulence. Example: Beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, wheat germ, alcohol, caffeine etc. 2. Lactose and gluten avoidance. 3. Low FODMAP diet-The elimination of dietary fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) has quickly gained popularity as a treatment for patients with IBS. FODMAPs lead to increased GI water secretion and increased fermentation in the colon, thus producing short chain fatty acids and gases which can lead to luminal distension and the triggering of meal related symptoms in patients with IBS. For example: foods that contain fructose like honey, highfructose corn syrup, apples, pears, mangoes, cherries etc should be avoided. 4. Dietary fibre – Should be restricted in diarrhoea predominant IBS. On the other hand, dietary fibre is helpful in constipation predominant IBS. Ex – Ispaghula husk. Goal is to take 10-15 gm fibre/day in incremental doses. 5. Food allergy testing – For guidance regarding specific foods. Please tell us in brief about peptic ulcer disease (PUD)? How do we treat and prevent recurrence of PUD? Peptic ulcer disease means ulceration in the stomach and duodenum due to acidpepsin digestion. It is a very common disease in gastroenterology. It is also common in our country. The point prevalence of gastric ulcer is (3.8) and that of duodenal ulcer disease is (9). Probably, it is highly reported globally. In the past it was thought that peptic ulcer disease is of unknown aetiology. But the fact that there is increased HCl secretion in the pathogenesis of PUD. Marshall and Warren in 1984 discovered gram negative bacteria (H.pylori) in the gastric mucosa and it is associated with gastritis, ulcer disease, gastric cancer and MALToma. With this discovery there is a great revolution in the field of gastroenterology. This is the most common bacteria infecting half of the population of the world. H.pylori is transmitted by faeco-oral route. It is commonly found where sanitation is poor and other water borne diseases are very common. It is also common in our country with 95% infection occurring in children by the age of five according to ICDDRB study. After the discovery of H.pylori the aetiopathogenesis of PUD are now clearly divided into three types i. H.pylori associated ii. NSAID associated iii. Miscellaneous Peptic ulcer disease clinically present with the complaints of epigastric pain. Epigastric pain is related with food and it is associated with dyspepsia, heaviness and fullness of the abdomen. There is periodicity and nocturnal pain. If the peptic ulcer disease is not properly treated they will produce narrowing of the lumen (gastric outlet obstruction) manifested by vomiting. Ulcer erodes the blood vessel in the stomach wall and produce hematemesis and melena. PUD is associated with acidpepsin digestion. When there was no drug available the only treatment was neutralization of pre-formed acid in the gastric lumen. This was the only treatment available during that period. With the knowledge of secretion of acid form gastric mucosa, the first generation of drug is H2A receptor antagonist like cimetidine, famotidine. Later on, more potent acid suppressor like PPI agents Omeprazole, Lansoprazole came to the market. These two groups of acid suppressors are treating ulcer disease adequately. But after the discovery of H.pylori the addition of antimicrobial has changed the treatment strategy. In one hand they eradicate the bacteria and in other hand they profoundly suppress acid secretion and prevent the complications and recurrences. Being available over the counter, patients now-a-days are self-prescribing and overusing anti-ulcerant drugs like PPIs. What are the consequences of such irrational use in long term? Proton pump inhibitors (PPIs) are Omeprozole, Lansoprazole, Pantoprazole etc. They are commonly prescribed by doctors logically and empirically. It is widely marketed and highly prescribed throughout the world. It has potent capacity of acid inhibition and relief from acid related complaints. With these benefits people are purchasing this drug from the medicine shop. They use it randomly. These drugs relieve their dyspepsia but also produce some dependencies. Besides this, if a person discontinues the drug there are some withdrawal effects (rebound acidity). All these factors make the person dependent on PPI. Every medication has some beneficial effects, as well as some side effects. After 30 years it is observed that prolonged user of PPI has many unwanted side effects. As PPI lowers intragastric PH it favors opportunistic bacteria and causes diarrhea. It is also associated with some malabsorption of certain nutrients like iron, calcium, magnesium, zinc and other trace elements. It has some side effect on kidney disease and brain disease (dementia). How common is GERD in our country? Can it lead to malignancy? How can we prevent such complications? Gastroesophageal reflux (GER) is a physiologic process by which gastric contents move retrograde from the stomach to the esophagus. GER itself is not a disease and occurs multiple times each day without producing symptoms or mucosal damage. In contrast GERD is a spectrum of disease usually producing symptoms of heartburn and acid regurgitation. GERD is a consequence of the failure of the normal anti-reflux barrier to protect against frequent and abnormal amounts of refluxed material. The prevalence of GERD is increasing in Western countries due to obesity epidemic. It is mainly manifested by heartburn. In a survey in western community, 25% people suffer from heart-

INTERVIEW 67 burn once a month, 12% suffer once a week and 5% suffer once a day. There is no statistical data in our country. But due to urbanisation, changes in food habit, younger generation are becoming more and more obese. They are frequently suffering from heartburn and GERD. The pathogenesis of GERD is complex, resulting from an imbalance between defensive factors and the aggressive factors protecting the esophagus. In long run the mucosa of the oesophagus changes into Barrett’s oesophagus and subsequently to oesophageal cancer of the lower end. If we take small sized frequent meal, avoid alcohol, coffee, carbonated drinks, do some physical exercise to maintain our body weight according to height and age and periodically check the mucosa of the oesophagus by upper GI endoscopy, we can prevent complications of GERD like Barrett’s oesophagus and oesophageal carcinoma. Where does Bangladesh stand as far as prevention, diagnosis and treatments of GI diseases are concerned, compared to the advanced countries? Bangladesh has been elevated to the status of a developing country recently. Some health-related parameters like MMR/ INR/ EPI/ safe drinking water / life span are better than our neighboring countries. These indices of health education, food sanitation, awareness help us in the prevention of communicable disease like cholera, diarrhoea etc. These communicable diseases were the major health problem in our country in the recent past but now-adays communicable disease in Bangladesh is gradually decreasing. These will reduce our health expenditure significantly. Our medical graduates and specialized doctors are updated in comparison to the western society. They are efficient in the diagnosis and treatment of GI diseases like advanced countries. You see when they are working abroad they become legendary in that area. But due to inadequate infrastructure we have some deficiencies in diagnosis. We are slightly lagging behind in diagnosis and management of the diseases. During the early days of Covid-19 pandemic, globally movements of people were restricted. In the pre-covid period, people could move abroad frequently for treatment. But during this period people couldn’t go to India, Singapore and other countries. The prevalence and morbidity are always present in a same magnitude. Our doctors are treating them for about one and a half year. The health professionals in our country are continuously managing the health hazards with utmost sincerity and devotion with some exception. We need active cooperation from the policy makers in this regard. l What’s on offer? The theme of the congress, which will gather experts from around the world, is “Innovating for the future of health care”, encompassing topics such as precision medicines, artificial intelligence and new ideas in drug discovery and development. A preliminary programme is expected in April. Innovations offer the potential of more accessible, efficient and cost-effective care towards a future where health care is truly patient-centric, preventive and sustainable. We invite you to join us in Cape Town, where experts in the pharmacy, pharmaceutical sciences and pharmacy education fields, will share the knowledge and new practices in healthcare delivery that are contributing to addressing global challenges. International discussions that shape the future of pharmacy take place at the FIP Council Meeting. Likely agenda items include policy statements on access to medicines, the roles of pharmacists in promoting a tobacco free future, and inter-professional working. The Council Meeting is scheduled to take place on 31 August (a day before the official opening of the congress) and 1 September. l 82nd World Congress of Pharmacy and Pharmaceutical Sciences Registration for the 2024 International Pharmaceutical Federation (FIP) World Congress of Pharmacy and Pharmaceutical Sciences is now open. This year, the congress will be held in Cape Town, South Africa, from 1-4 September. FIP NEWS

INTERVIEW 69 Would you please tell us about the prevalence of liver diseases in Bangladesh? According to the latest WHO data published in 2020 Liver Disease Deaths in Bangladesh reached 21,024 or 2.94% of total deaths. The age adjusted death rate is 16.64 per 100,000 of population, ranks Bangladesh #101 in the world. The number of people suffering from liver diseases in Bangladesh is increasing at an alarming rate as about 40 million people are somehow suffering from the disease. About 15 million people are now suffering from the chronic liver disease hepatitis-B virus, 800,000 people from hepatitis-C virus and nearly 20 million people are suffering from other liver- related diseases like liver cirrhosis, cancer and fatty liver disease. The cause of the 43 percent cases admitted to hospitals with acute hepatitis and jaundice was hepatitis E virus, 22 percent cases by hepatitis B, 8 percent was hepatitis A and 3 percent was hepatitis C. Please tell us, in brief about the prevalence of viral hepatitis in Bangladesh. What can be done to eliminate Hepatitis B from the country? Prevalence of HBV is 2.16% (according to APASAL HBV in pregnancy 2022) and prevalence of HCV is 0.6 %. Persons Who Are HBsAg Positive: Should use barrier protection during sexual intercourse if partner is not vaccinated or is not naturally immune. Not share toothbrushes or razors and not share injection equipment. Avoid sharing glucose testing equipment. Cover open cuts and scratches and clean blood spills with bleach solution. Avoid blood donation, organs, or sperm. Children and Adults Who Are HBsAg Positive: Can participate in all activities, including contact sports. Should not be excluded from daycare or school participation and should not be isolated from other children. Can share food and utensils and kiss others. According to expert opinion, to prevent HBV transmission from a hepatitis B-infected mother to her child, every pregnant woman should be tested for HBV, and all children should receive the first dose of vaccine within 24hrs of birth (birth dose), followed by two doses. However, commercial vaccines are not available for hepatitis C infection. What are the chances of someone with HCV infection developing cirrhosis or liver cancer? What are the risk factors? The chances of someone with HCV infection developing cirrhosis or liver cancer vary depending on several factors-including: individuals overall health, duration of the infection, whether they receive treatment or not. However without treatment, approximately 15-30% of individual with chronic HCV infection will develop cirrhosis over 20-30 years and about 1-5% will develop liver cancer within 30 years. Early detection & treatment can significantly reduce the risk of developing these serious complications. Several risk factors contribute to the development of cirrhosis of liver and HCC in chronic HCV infection a. Duration & infection - longer a person is infected with HCV, the higher the risk of developing cirrhosis and HCC. b. Age at infection - people who are infected at a younger age are more - likely to progress to cirrhosis & HCC. c. Alcohol Consumption - excessive alcohol intake can accelerate liver damage in individuals with HCV infection. d. Co-infection with other viruses: HBV, HIV can increase the rise of liver damage. e. Obesity - obesity & NAFLD can exacerbate liver damage with HCV infection. f. Genetics - certain genetic factory predispose individuals to more rapid progression of liver disease. g. Male gender - male more than female are at higher risk of developing cirrhosis with HCV infection. h. Immunosuppression - Risk of liver damage. i. Poor Liver health other associated liver disease - fatty liver disease, AIH. To prevent HBV transmission from a hepatitis B-infected mother to her child, every pregnant woman should be tested for HBV Prof. Dr. Ayub Al Mamun Chairman, Dept. of Hepatology BSMMU

70 INTERVIEW What are the risk factors of developing Non-Alcoholic Fatty Liver Disease (NAFLD)? How often can NAFLD progress to Non-Alcoholic Steatohepatitis? What can be done to prevent it? Non-alcoholic fatty liver disease (NAFLD) can develop due to a variety of factors. Here are some of the main risk factors associated with its development: a. Obesity: Excess body weight, especially central obesity (carrying weight around the waist), is strongly associated with NAFLD. b. Insulin resistance: When cells in your body don’t respond well to insulin and cannot efficiently take up glucose from the bloodstream, it can lead to high blood sugar levels. This insulin resistance is closely linked to NAFLD. c. Type 2 diabetes: People with diabetes are at an increased risk of NAFLD. The relationship between the two conditions is complex, as NAFLD can contribute to the development of diabetes and vice versa. d. High cholesterol and triglyceride levels: Elevated levels of cholesterol and triglycerides in the blood are associated with NAFLD. e. Metabolic syndrome: This is a cluster of conditions including high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. People with metabolic syndrome are at a higher risk of developing NAFLD. f. Sedentary lifestyle: Lack of physical activity can contribute to the development of NAFLD. Regular exercise helps control weight, improve insulin sensitivity, and lower blood sugar and cholesterol levels. g. Unhealthy diet: Diets high in processed foods, refined carbohydrates, and sugars can increase the risk of NAFLD. High fructose consumption, in particular, has been linked to NAFLD development. h. Age: NAFLD can occur at any age but is more common in middle-aged and older adults. i. Genetics: Genetics can play a role in NAFLD development. Some people may be genetically predisposed to accumulate fat in the liver or to have difficulty metabolizing fat. j. Medications: Certain medications, such as corticosteroids, tamoxifen, and some antiretroviral drugs, may increase the risk of NAFLD. k. Sleep apnea: There is evidence to suggest that sleep apnea, a disorder characterized by pauses in breathing during sleep, is associated with NAFLD. However, these risk factors can vary in importance from person to person, and having one or more of them does not necessarily mean that you will develop NAFLD. Globally, the overall prevalence of NAFLD is 25%. While the prevalence of the progressive form of NAFLD or NASH is between 12% to 14%. The highest prevalence rates for NAFLD and NASH have been reported from the Middle Eastern countries. Approximately 20% of individuals with NAFLD have NASH, and some cases may progress to cirrhosis and hepatocellular carcinoma (HCC). Preventing non-alcoholic fatty liver disease (NAFLD) involves adopting a healthy lifestyle and addressing underlying risk factors. Here are some strategies: a. Maintain a healthy weight: If you’re overweight or obese, losing weight gradually through a combination of healthy eating and regular exercise can help reduce fat accumulation in the liver and improve liver health. b. Follow a balanced diet: Focus on eating a diet rich in fruits, vegetables, whole grains, and lean proteins. Limit your intake of processed foods, sugary drinks, and foods high in saturated fats and refined carbohydrates. Avoid excessive consumption of high-fructose corn syrup and sugary snacks. c. Exercise regularly: Engage in regular physical activity, aiming for at least 150 minutes of moderate-intensity aerobic exercise per week, such as brisk walking, cycling, or swimming. Exercise helps improve insulin sensitivity, aids in weight loss, and promotes overall liver health. d. Limit alcohol consumption: Even though NAFLD is not caused by alcohol consumption, excessive alcohol intake can exacerbate liver damage. Limit alcohol consumption to recommended levels (up to one drink per day for women and up to two drinks per day for men). e. Manage underlying health conditions: If you have conditions like diabetes, high blood pressure, or high cholesterol, work with your healthcare provider to manage them effectively through medication, diet, and lifestyle modifications. f. Avoid crash diets and rapid weight loss: Rapid weight loss or crash diets can lead to the release of toxins from fat cells, potentially harming the liver. Focus on gradual, sustainable weight loss through healthy eating and regular exercise. g. Be cautious with medications and supplements: Some medications and supplements can affect liver health. Always follow your healthcare provider’s recommendations regarding medications and be cautious with herbal supplements, especially if you have liver disease. h. Get regular medical check-ups: Regular health screenings can help detect and manage risk factors for NAFLD, such as obesity, diabetes, and high cholesterol, before they lead to liver damage. i. Maintain good sleep hygiene: Poor sleep quality and sleep disorders like sleep apnea have been linked to NAFLD. Aim for 7-9 hours of quality sleep per night and seek treatment if you have sleep-related issues. j. Avoid smoking: Smoking has been associated with an increased risk of liver disease and can worsen existing liver conditions. If you smoke, consider quitting, and avoid exposure to secondhand smoke. How effective is stem cell therapy for end stage liver disease? Is it compatible with the socio-economic condition of our country? Administration of stem cell has been reported to be well tolerated and safe, and confers beneficial effects in patients with liver failure, by enhancing liver function and reducing Child-Pugh and MELD scores, ascites, and overall mortality. However, some concerns and critical issues remain unanswered regarding the longterm safety and efficacy of clinical stem cell therapies. It may not be compatible with our socio-economic condition at this moment but in the very near future it will become affordable if government and non-government organizations come forward. Stem cell therapy in Bangladesh indicates that cell therapy may be accomplished in general hospitals of developing countries if the proper design and mild to moderate types of invasive approaches are utilized. l

It’s the holy grail for some people: how to possibly slow aging or wind back our body’s biological clock despite the years ticking by and if it’s as simple as taking a daily pill, then even better. Vitamin D has long been a favored candidate since it’s important for building muscle and bone, which typically waste away or weaken as we age. Studies show that without enough vitamin D, people’s age-related risk of muscle loss and falls increases. So, would taking a vitamin D supplement help slow that decline, or even turn it right around? Clinicians have for decades recommended vitamin D supplements for people with osteoporosis and to help prevent bone fractures because a lack of vitamin D has been linked to those conditions. That makes sense because vitamin D helps with calcium absorption. Although vitamin D is found in certain foods, it can be difficult to get enough from your diet alone or if you don’t get enough sun exposure. But more recent clinical trials have found that vitamin D supplements don’t necessarily help prevent age-related bone loss and fractures in otherwise healthy people. Some studies suggest vitamin D can slow epigenetic aging since people with low vitamin D levels are biologically older than those with adequate levels. Vitamin D supplementation might also help reduce DNA damage but it does not seem to have an impact on telomere length. There’s also very little evidence about what dose or at what age vitamin D supplements might have an effect, because there are so few human studies, and the findings have been mixed. Some studies suggest taking a specific dose of vitamin D would be safe for the general population, but that might not be true for everyone. Research shows that taking high doses of vitamin D can be harmful. Vitamin D supplements can also interact with prescription medicines, such as cholesterollowering statins. And while it might seem logical to top up low levels of vitamin D,experts say consuming more vitamins in supplement form isn’t necessarily better for health. It could lead people to disregard other things they can do to improve their health and live longer, like eating a balanced diet or getting outdoors. “Despite the interest in vitamin D supplementation as a strategy supporting human longevity and some evidence about its potential in modulating hallmarks of aging, we are still far from the point of translation from bench to bed,” Researchers added. l Source: Science Alert Could vitamin D be the secret to slowing human aging? DID YOU KNOW? Antibiotics probably won’t ease your Cough, even if Infection is Bacterial Doctors sometimes prescribe antibiotics to help treat a cough, but a new study shows the drugs won’t help reduce the severity or duration of coughing – even if a bacterial infection is the culprit. Lower respiratory tract infections that cause coughing have the potential to become more dangerous, with 3% to 5% of these patients suffering from pneumonia, says a study. “But not everyone has easy access at an initial visit to an X-ray, which may be the reason clinicians still give antibiotics without any other evidence of a bacterial infection,” says the authors. This has led some patients to expect antibiotics for a cough, they added. To see if antibiotics make any difference, researchers tracked their use in people presenting with lower respiratory tract infections. About 29% of people were prescribed an antibiotic during their initial medical visit, but the drugs had no effect on their cough compared to those who didn’t get a prescription. It also took the same amount of time for people to get over their infection, whether or not they got an antibiotic – about 17 days. The new study was published in the Journal of General Internal Medicine. Overuse of antibiotics is increasing the risk that dangerous bacteria will become resistant to the drugs, researchers noted. “We know that cough can be an indicator of a serious problem. It is the most common illness-related reason for an ambulatory care visit, accounting for nearly 3 million outpatient visits and more than 4 million emergency department visits annually,” researchers said. “Serious cough symptoms and how to treat them properly needs to be studied more, perhaps in a randomized clinical trial as this study was observational and there haven’t been any randomized trials looking at this issue since about 2012,” study added. FEATURE 71

72 AMR A call to change narratives around AMR The current language used to describe antimicrobial and antibiotic resistance to non-experts is a barrier to effective policymaking, resource mobilization, and overall progress in the field. Public messaging around antibiotics often lacks information about the consequences of antibiotic use at the individual level, such as the disruption of human gut microbiomes. The authors call for multisectoral discussions to improve the language and messaging by agreeing on a common vision and formulating more appropriate narratives tailored to local contexts. l Opportunities and challenges of AI in antibiotic stewardship Chatbots are a subtype of artificial intelligence that allow for natural language interactions with users. In the context of antibiotic resistance, chatbots can integrate data from electronic health records and laboratory information systems to provide clinical recommendations and optimize antibiotic efficacy based on patients’ responses to treatment. Despite the myriad of potential applications of chatbots in antibiotic stewardship, their ability to access medical records and inherent dependence on technology raises concerns about privacy and medical ethics. l The impact of gender and caste discrimination and climate change on AMR Source: One Health Trust The One Health Trust recently hosted a twoday workshop funded by the World Health Organization and the British Academy (Bangalore, India) on gender and caste inequities, climate change, and antimicrobial resistance (AMR). The workshop participants – from fields including climate science, gender studies, pharmaceutical sciences, and more – provided diverse perspectives on drug-resistant infections and potential solutions to control their spread. From ensuring women are included in clinical trials to establish inclusive prescribing guidelines for new antibiotic treatments to improving access to drinking water and menstruation products and promoting education to reduce stigma around gynecological issues and sexually transmitted diseases, the experts emphasized the need to work across disciplines and sectors to effectively mitigate AMR. l FAST FACTS According to current World Health Organization (WHO) figures, an estimated 1.3 billion people have a significant disability, accounting for 16% of the global population– that is, one in every six of us. According to data of the Kidney Foundation, Bangladesh, at least 54 patients with kidney related complications die in the country every day. At present, approximately 20 million individuals in Bangladesh are grappling with kidney related ailments, including nearly 80,000 with end stage kidney failure, while around 40,000 die every year. According to a recent study, heart, lung and brain diseases together are responsible for 36 per cent of all deaths in the country. According to the WHO data, stroke kills 81.6 per cent females and 82.9 per cent males out of 0.1 million population in 2019. As per a recent study, too much salt is deadly. At least 1.9 million deaths annually are attributed to excess sodium consumption.

PHARMACOVIGILANCE 73 IN 1938 the Food, Drug and Cosmetic Act (FFDCA, FDCA, or FD&C) was established in the United States, a set of laws to charge the Food and Drug Administration (FDA) with supervising the safety of foods, drugs, medical devices and cosmetics, laying the foundations of pharmaceutical legislation. IN 1948, the World Health Organization (WHO) was founded in Geneva to centralize health issues worldwide. IN 1962, following the Thalidomide accident, the Harris-Kefauver amendments were introduced in the United States, which mandated the need to conduct mandatory preclinical studies. Only after the evaluation of the results of these studies was it possible to start the clinical trial phase on humans. IN 1964, the first form for reporting adverse reactions by doctors, was introduced in the United Kingdom. IN 1968, the WHO promoted the Program on International Drug Monitoring (PIDM), an international drug monitoring program aimed at centralizing global data on adverse reactions. 10 states were initially involved: Australia, Canada, Czechoslovakia, Ireland, the Netherlands, Germany, New Zealand, Sweden, the United Kingdom, the USA (Italy joined in 1975. IN 1973, France inaugurated the first six hospital surveillance centers, where the term pharmacovigilance was formally adopted. IN 1978, the Swedish government and the WHO founded the Uppsala monitoring center. IN 1995, the European Medicines Agency (EMA) was founded. In 2001, Eudravigilance, the European database for the management of reports, was implemented. IN 2001, the National Pharmacovigilance Network (RNF) was created in Italy to collect reports of adverse reactions at a national level. IN 2003, the Italian Medicines Agency (AIFA) was created. As proof of the growing awareness at a national level, some collaborative groups were established such as the Interregional Pharmacovigilance Group (GIF) and the Italian Group for Epidemiological Studies in Dermatology (GISED). IN 2012, with the establishment of the Pharmacovigilance Risk Assessment Committee (PRAC), the European pharmacovigilance system was further strengthened, clearly defining roles and responsibilities. The PRAC is responsible for evaluating and monitoring the safety of medicines for human use, providing recommendations to the relevant committees. l Following these events, the first bodies and procedures emerged aimed at monitoring the safety of the drug History of pharmacovigilance SOURCE: UMC There is always promise and excitement within pharmacovigilance to be able to leverage technological advances. Currently, technologies are being increasingly trusted to reduce the cost of current activities and to potentially improve how patient benefit-risk is assessed. It is important, however, to note that pharmacovigilance activities in a pharmaceutical company must adhere to a diverse set of legal regulations that dictate how activities are conducted across the entire pharmacovigilance cycle. These regulatory frameworks are themselves complex and made further complicated by the many variations that exist worldwide. Pharmaceutical company processes align around these diverse regulations to ensure the integrity of pharmacovigilance activities. It is these activities, which are essential to ensuring patient safety, maintaining trust by the public in medicines and vaccines, and for maintaining trust in AI/ML tools by all stakeholders, where global harmonisation is important to reduce unnecessary effort and maintain focus on tasks benefiting patient safety. To ensure appropriate use of the technology, assessment of AI/ML outputs and related processes is arguably growing in importance given the increasing complexity of AI/ML and the potential use of LLMs. It is suggested that ensuring trust in AI/ML technology can make use of existing risk-based pharmacovigilance processes as a framework. The future of trust in AI/ML could focus on monitoring the outcomes of a process for safety, reliability, and effectiveness. Using a risk-based approach could help ensure that any change in or impact on business processes is fully understood and can be successfully managed. Moreover, it should involve all stakeholders working closely together to harmonise on a process for implementing and monitoring AI/ML. This way, responsible data access to all partners in the pharmacovigilance ecosystem will be assured. By utilising a modified and simplified version of existing pharmacovigilance system frameworks, and focusing on the safety, reliability, and effectiveness of the output of AI/ML systems rather than the dataset and algorithm itself, we may build trust in AI/ML much like we do for existing technologies. Building trust ensures that when a pharmaceutical company takes a systematic approach to assess and monitor the quality of data inputs and outputs, with targeted spot checking that is proportional to risk, a pharmacovigilance organisation can successfully balance the goals of ensuring patient safety while making the most use of the advantages of an AI/ML system. However, patient safety remains the unwavering focus of all pharmacovigilance activities. AI/ML systems offer great promise in improving operational processes to free human resources for higher-value activities and providing insights that might not be possible otherwise. By working together to rethink and harmonise the global regulatory framework, and by focusing on technological outputs rather than the technology itself, the potential of AI/ML can be unlocked to enable advances in better understanding the benefit-risk of medicines and vaccines for patients without compromising on patient safety. l HOW DO WE ENSURE TRUST IN AI/ML WHEN USED IN PHARMACOVIGILANCE?

74 DRUG SAFETY DABIGATRAN ETEXILATE METHANESULFONATE Risk of oesophageal ulcer, oesophagitis The MHLW and the PMDA have announced that the product information for dabigatran etexilate methanesulfonate will be updated to include the risk of oesophageal ulcer and oesophagitis. Dabigatran etexilate methanesulfonate is indicated for reduction in the risk of ischaemic stroke and systemic embolism in patients with non-valvular atrial fibrillation. The MHLW and the PMDA assessed 49 cases involving oesophageal ulcer or oesophagitis in Japan, and concluded that a causal relationship between dabigatran etexilate methanesulfonate and oesophageal ulcer or oesophagitis was reasonably possible. ATORVASTATIN Risk of erectile dysfunction The Saudi Food & Drug Authority (SFDA) has released a safety signal concerning atorvastatin and risk of erectile dysfunction. Atorvastatin is a potent, orally available inhibitor of hepatic 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, the major rate-limiting enzyme in cholesterol synthesis. The current primary indication for atorvastatin is the treatment of hypercholesterolemia in persons at high risk for coronary, cerebrovascular and peripheral artery disease. DOMPERIDONE Potential risk of psychiatric withdrawal events when used for lactation stimulation Health Canada has announced that the product information for domperidone is to be updated to include the potential risk of psychiatric withdrawal events when used for lactation stimulation. Domperidone is authorized for sale in Canada to treat symptoms of slowed stomach emptying seen with certain gastrointestinal conditions, and to prevent symptoms, such as nausea and vomiting, caused by some drugs used to treat Parkinson’s disease. Domperidone is not authorized in Canada to promote lactation, but data derived from Canadian sources indicate that it has been prescribed for this off-label use. Canada also reviewed articles published in the scientific literature, which identified potential biological mechanisms that may explain how sudden discontinuation or tapering of domperidone, when used to stimulate lactation, could lead to psychiatric withdrawal events. OLAPARIB Risk of hepatotoxicity The PRAC of the EMA has recommended updating the product information for olaparib (Lynparza®) to add the risk of hepatotoxicity including hepatobiliary disorders, drug-induced liver injury (DILI) and transaminases increased. Olaparib is indicated for the treatment of BRCAmutated advanced ovarian cancer in adults. The PRAC reviewed the available evidence including from EudraVigilance and agreed the recommendation. Health-care professionals are advised that if clinical symptoms or signs suggestive of hepatotoxicity develop, prompt clinical evaluation of the patient and measurement of liver function tests should be performed. In case of suspected DILI, treatment should be interrupted. In case of severe DILI treatment discontinuation should be considered as clinically appropriate. KETAMINE Risk of prolonged use leads to severe liver and uro-nephrological damage The ANSM is reminding health-care professionals by issuing a Direct Healthcare Professional Communication (DHPC) that there is an increase in the number of hepatobiliary (cholestasis or cholangitis) and uro-nephrological (non-infectious cystitis, interstitial cystitis, acute renal failure, hydronephrosis), most often serious, after prolonged or repeated use of ketamine. Ketamine is a narcotic whose prescription is limited to 28 days. The ANSM reminded health-care professional to respect the recommended dosages of ketamine and to limit exposure over time, and monitor liver function, renal function and urinary cytology closely if taken repeatedly or over prolonged time. ETOPOSIDE Risk of electrolyte imbalance The SFDA has released a safety signal concerning etoposide and risk of electrolyte imbalance. Etoposide is a semisynthetic analogue of podophyllotoxin that is used as antineoplastic agent in the therapy of several forms of solid tumours, leukaemia and lymphoma, usually in combination with other agents. In 2023, the SFDA has detected a signal of etoposide and electrolyte imbalance and reviewed all the evidence available on the association between them. The SFDA initiated this investigation following two local case-report of electrolyte imbalance in SFDA vigilance database. The SFDA looked into VigiBase and found 88 ICSRs and extracted cases with completeness score of 0.8 and above (ICSRs = 8) in order to apply the causality assessment criteria on them. As a result, most of the assessed cases provides positive linkage to etoposide (5 possible cases, 1 unlikely case, and 2 not assessable cases).

RED ALERT 75 LEVETIRACETAM, CLOBAZAM Risk of drug reaction with eosinophilia and systemic symptoms (DRESS) The US Food and Drug Administration (FDA) is warning that levetiracetam and clobazam can cause drug reaction with eosinophilia and systemic symptoms (DRESS). DRESS is a rare but serious reaction that can be life-threatening if not diagnosed and treated quickly. It may start as a rash but can quickly progress, resulting in injury to internal organs, the need for hospitalization, and even death. Health-care professionals should be aware that prompt recognition and early treatment is important for improving DRESS outcomes and decreasing mortality. DRESS can develop 2-8 weeks after starting the medicines, and symptoms and intensity can vary widely. The MHRA has announced that the product information for all statins is being updated to list myasthenia gravis and ocular myasthenia gravis as adverse drug reactions. Globally, there has been a very small number of reports of new-onset or aggravation of pre-existing myasthenia gravis with statins. A recent European review recommended new warnings on the risk of new onset or aggravation of preexisting myasthenia gravis with multiple statins. Health-care professionals should advise patients taking statins to consult their doctor if they experience weakness in the arms or legs that worsens after periods of activity, double vision or drooping of eyelids, difficulty swallowing, or shortness of breath. FLUOROQUINOLONE ANTIBIOTICS Risk of suicidal thoughts and behaviour The MHRA has reminded health-care professionals to be alert to the risk of psychiatric reactions, including depression and psychotic reactions, which may potentially lead to thoughts of suicide or suicide attempts. The MHRA has received a coroner’s report following the death of a patient who died by suicide after being treated with ciprofloxacin. Warnings on the potential for psychiatric adverse drug reactions to occur with ciprofloxacin and other fluoroquinolones are included in the product information. In rare cases, depression or psychosis can progress to suicidal ideation or suicide attempts. If this happens, ciprofloxacin should be discontinued immediately. Health-care professionals are also reminded to advise patients to be alert to these risks. PROTON PUMP INHIBITORS (PPIS) Risk of acute tubulointerstitial nephritis (TIN) The South African Health Products Regulatory Authority (SAHPRA) has alerted health-care professionals on the risk of acute tubulointerstitial nephritis (TIN) associated with use of Proton Pump Inhibitors (PPIs: pantoprazole, dexlansoprazole, esomeprazole, and rabeprazole). TIN (previously called interstitial nephritis) is characterized by an inflammatory reaction within the tubulointerstitial space of the kidney, and acute TIN can result in acute kidney injury. Symptoms and signs of acute TIN may be nonspecific and are often absent unless symptoms and signs of renal failure develop. Many patients develop polyuria (increased frequency of urination) and nocturia (the need for patients to get up at night on a regular basis to urinate). Health-care professionals are advised that treatment by PPIs must be stopped when TIN is suspected; PPIs are contraindicated in patients who previously experienced TIN while on treatment with PPIs; and patients should be asked to report any alteration in urine volumes or if they suspect that there is blood in their urine while on PPIs. BACLOFEN Risk of overdose on off-label use The Therapeutic Goods Administration (TGA) has alerted health-care professionals on the risk of overdose of baclofen tablet form, particularly when baclofen is used off-label at higher doses for the treatment of alcohol-use disorder. The product information for baclofen includes warnings about the risk of suicide and suicide-related events, recommending close supervision of patients with alcohol-use disorder, depression and/or a history of previous suicide attempts. The optimum dosage listed in the product information ranges from 30 to 75 mg daily, although occasionally doses up to 100 mg daily may be necessary in hospitalised patients. STATINS Potential risk of myasthenia gravis and ocular myasthenia gravis

INTERVIEW 77 Our Association for the study of liver disease is dedicated to advancing liver health in Bangladesh through comprehensive efforts in research, education, advocacy, and patient care Prof. Dr. Faroque Ahmed Head, Dept. of Hepatology DMCH Hepatitis B & C viral infection can cause chronic liver disease, cirrhosis and its complications to liver cancer. Those who are infected must consult with specialist physician for appropriate treatment and regular monitoring. As we know, prevention is far better than treatment, following measures can be disseminated to common people through print, electronic media, seminars, conferences and other direct audio visual contacts. l All children and also adults should take vaccine for hepatitis B, especially health care workers and family members of Hepatitis B & C infected patients must also be vaccinated. l Avoid sharing personal items used as toothbrush, razors etc. l Avoid sharing needle use in drug, tattooing, body piercing. l Practice safe sex. l Ensure screening of donated blood before transfusion of blood or blood products. Proper treatment of Hepatitis B, C infected patients can prevent liver cirrhosis and liver cancer. So, we must convince our surrounding people to disseminate this information to help eliminate hepatitis by 2030. As a pioneer Hepatologist of our country, would you please tell us, where does Bangladesh stand as far as prevention, diagnosis and treatment of Liver diseases are concerned, compared to the advanced countries? As a pioneer Hepatologist in Bangladesh, you likely have a unique perspective on the country’s standing in liver disease prevention, diagnosis, and treatment compared to advanced countries. While Bangladesh may face challenges such as limited resources and infrastructure, there have likely been significant advancements made in recent years, particularly in raising awareness, improving diagnostics, and implementing treatment strategies tailored to the local context. Collaborations with international experts and organizations could further enhance Bangladesh’s capacity in managing liver diseases effectively. What are the chances of someone with HCV infection developing cirrhosis or liver cancer? What are the risk factors? The chances of someone with HCV (Hepatitis C Virus) infection developing cirrhosis or liver cancer vary depending on several factors such as the individual’s age, overall health, duration of infection, and whether they receive treatment. Without treatment, approximately 15-30% of individuals with chronic HCV infection will develop cirrhosis over 20-30 years. However, with advances in antiviral therapies, the risk of progression to cirrhosis has decreased significantly. Regarding liver cancer (hepatocellular carcinoma or HCC), individuals with chronic HCV infection are at an increased risk compared to the general population. It’s estimated that around 1-5% of individuals with chronic HCV infection will develop liver cancer over a 20-30 years period. Risk factors for progression to cirrhosis and liver cancer in individuals with HCV infection include: i. Duration of infection: Longer duration of infection increases the risk. ii. Age: Older individuals are at a higher risk of developing complications. iii. Alcohol consumption: Heavy alcohol use can accelerate liver damage in individuals with HCV infection. iv. Co-infection: Having other liver infections such as hepatitis B or HIV can worsen liver damage. v. Obesity: Obesity and related conditions such as non-alcoholic fatty liver disease (NAFLD) can exacerbate liver damage. vi. Genetics: Certain genetic factors can influence the progression of liver disease individuals with HCV infection. Early diagnosis and treatment of HCV infection are crucial in reducing the risk of deAs an eminent Hepatologist of the country, would you please let us know about the prevalence of Liver Diseases in our country? Prevalence of various Liver diseases varies in different parts of the world. In Bangladesh prevalence of the common liver diseases are non-alcohol liver diseases 33% (approx.), chronic Hepatitis B 5.7%, chronic Hepatitis C 1% (approx.), according to several population based studies. About 20,000 people die each year due to chronic liver disease and its various complications. Please tell us, in brief, about the prevalence of Viral Hepatitis in Bangladesh? What are your suggestions to create awareness among the common people about viral Hepatitis? In Bangladesh, various population based study showed that prevalence of Hepatitis B is 5.7% and Hepatitis C is 1% (approx.). Though recent studies, revealed further decline in prevalence.

INTERVIEW 79 veloping cirrhosis and liver cancer. Additionally, lifestyle modifications such as avoiding alcohol, maintaining a healthy weight, and regular medical monitoring can help mitigate risks associated with HCV infection. As the vice president of Association for the Study of Liver Disease, Bangladesh, would you please tell us about the role of your organization regarding hepatic disorders in Bangladesh? As the Vice President of the Association for the Study of Liver Disease in Bangladesh, our organization plays a crucial role in addressing hepatic disorders in the country through various initiatives: i. Awareness and Education: We work to raise awareness about liver diseases, their risk factors, prevention, and treatment options among healthcare professionals, policymakers, and the general public through seminars, workshops, and educational campaigns. ii. Research and Advocacy: Our association conducts and supports research on liver diseases prevalent in Bangladesh, aiming to improve understanding, diagnosis, and management strategies. We also advocate for policies and programs that promote liver health and access to quality healthcare services. iii. Training and Capacity Building: We provide training and capacity-building opportunities for healthcare professionals, including physicians, nurses, and allied health workers, to enhance their knowledge and skills in the diagnosis and management of liver diseases. iv. Collaboration and Networking: We collaborate with national and international organizations, academic institutions, and healthcare providers to exchange knowledge, share best practices, and strengthen efforts to combat liver diseases in Bangladesh. v. Patient Support: We offer support services and resources for patients living with liver diseases, including information, counseling, and referrals to appropriate healthcare facilities for further evaluation and treatment. Overall, our Association for the study of liver disease is dedicated to advancing liver health in Bangladesh through comprehensive efforts in research, education, advocacy, and patient care. Treatment of liver diseases is quite expensive. How can you make it affordable for the common people? Making treatment for liver diseases more affordable for common people involves several strategies: i. Government Subsidies and Funding: Advocate for government subsidies or funding to make essential medications and treatments more affordable for patients with liver diseases. This could involve negotiating with pharmaceutical companies for lower prices or providing financial assistance programs for patients in need. ii. Generic Medications: Encourage the use of generic medications, which are often more affordable than brandname drugs. This can be achieved through policies that promote the production and distribution of generic versions of essential medications liver diseases. iii. Health Insurance Coverage: Advocate for improved health insurance coverage for liver diseases, including screening, diagnosis, treatment, and follow-up care. This could involve expanding existing health insurance programs or implementing new initiatives specifically targeting liver disease care. iv. Public Health Programs: Implement public health programs aimed at preventing liver diseases through vaccination (e.g. hepatitis B vaccination), screening and early detection liver diseases, and promoting healthy lifestyle behaviors to reduce the risk of liver disease development. v. Community-based Care: Develop community-based care models that provide comprehensive, cost-effective care for patients with liver diseases. This could involve integrating liver disease care into existing primary care services and leveraging community health workers to support patients in managing their condition. vi. Negotiating Treatment Costs: Negotiate with healthcare providers and pharmaceutical companies to lower the cost of treatments and procedures for liver diseases. This could involve bulk purchasing agreements, price negotiations, or implementing cost-sharing arrangements to reduce the financial burden on patients. vii.Research and Innovation: Invest in research and innovation to develop more affordable treatment options for liver diseases, such as new medications, medical devices, or treatment protocols that are cost-effective and accessible to a wider population. By implementing these strategies, it’s possible to make treatment for liver diseases more affordable and accessible for common people, thereby improving health outcomes and reducing the burden of liver diseases on individuals and communities. l FAST FACTS According to a study, assisted by WHO, more than 3 billion people worldwide were living with a neurological condition in 2021. High income countries have up to 70 times more neurological professionals per 100,000 people than low - and middle-income countries. More than 80% of neurological deaths and health loss occur in low and middle-income countries and access treatment varies widely, says a new study report in The Lancet Neurology. According to a study, the health service is about 20-30 per cent costlier in Bangladesh than neighboring country India. According to the WHO report in 2022, the probability of premature death due to the four major NCDs in Bangladesh is 19%. According to report of IQVIA, in 2023, drugs sales grew 2 percent to Tk. 30,059 crore, far lower than the four year average of 8.5 percent in 2022. According to WHO, about 0.9 million children aged under five died from pneumonia in the globe in 2017 accounting for 15 per cent of the total child death of the same age.

INTERVIEW 81 To reduce the mortality for ACLF, liver transplant facilities and liver intensive care facilities are essential for Bangladesh Prof. Dr. Shahinul Alam Professor Dept. of Hepatology BSMMU, Dhaka lation-based study of 2018 prevalence of hepatitis B is 5.1%. The estimated number of sufferers of hepatitis B in Bangladesh is 8.5 million, males are 5.7 million, and females are 2.8 million. Among them, the childbearing age lady is 1.8 million, service-seeking young persons (age 18 to 30 years) are 2.5 million, and 0.4 million are children. For successful immunization programs, hepatitis B is gradually decreasing. Recent meta-analysis for multiple studies revealed prevalence is 4% in 2022. Hepatitis B is responsible for 60% cases of cirrhosis and 65% cases of liver cancer. The prevalence of hepatitis C is also decreasing and it is 0.2% in Bangladesh. With the Blood Transfusion Act transmission through blood and blood products it is significantly decreasing. Transmission through surgical procedures and dialysis is significant in Bangladesh. Hepatitis C is the cause of 30 % cases of cirrhosis and 17 % cases of liver cancer. Suggestion to create awareness: Every 9 in 10 people do not know that they have HBV or HCV. If a program to do tests for HBV and HCV is mandatory for every NID, that will create maximum awareness. How common is fatty liver disease in our country? What are the risk factors? What lifestyle changes do you suggest to fatty liver patients? The prevalence of fatty liver disease is 33.86%. So, 45 million people have been suffering from fatty liver disease in Bangladesh. Mid-life female living in rural areas has the highest prevalence of fatty liver disease. It is alarming that fatty liver in children is progressively increasing. About 10 million people in Bangladesh are at risk of developing chronic liver disease because of fatty liver disease, fortunately, that is preventable. Fatty liver is the most common cause of chronic liver disease in Bangladesh at present status. Obesity and diabetes are the major risk factors for fatty liver disease. Rice-based calorie-rich dietary habits and low activity/ sitting time of more than 5 hours in a day are the reasons for fatty liver in Bangladesh. Increasing physical activities by walking and exercise and dietary restriction for a calorie-dense diet (sugar, beverage, rice, fast food) may prevent and cure fatty liver disease. What is the role of Plasma exchange (PLEX) in Acute on Chronic Liver Failure (ACLF)? What can be done to reduce the mortality rate in ACLF? Acute on Chronic Liver Failure (ACLF) is a serious condition with a high mortality rate. Plasma exchange is available in Bangladesh for many years. It has been utilized as a bridge to liver transplantation. It also has an increase in transplant-free survival in ACLF. To reduce the mortality for ACLF, liver transplant facilities and liver intensive care facilities are essential for Bangladesh. Please tell us in brief about Hepatocellular Carcinoma (HCC) and its treatment? Hepatocellular carcinoma is the 3rd most common cause of cancer in Bangladesh. The commonest cause of liver cancer of hepatitis B in Bangladesh. The upcoming cause of liver cancer is fatty liver. Treatment of liver cancer includes resection, transplantation, ablation, transarterial chemoembolization (TACE), systemic therapy, and immunotherapy. All modalities of treatment are available in Bangladesh except transplantation. Where does Bangladesh stand as far as prevention, diagnosis and treatments of liver diseases are concerned, compared to the advanced countries? At least 1 in every 3 people has been suffering from liver disease in Bangladesh. Bangladesh may be far at sight to be in the level of developed countries for the treatment of liver disease. At least 1500 liver specialists are needed to serve the people of the country. Transplant facility is an immediate need for the country. To improve the facilities, development of manpower, infrastructure, and logistics up to Upazila level is essential. Facilities for liver disease must be decentralized in the country up to the grass-root level. l As an eminent Hepatologist of the country, would you please let us know about the prevalence of liver diseases in our country? As per the World Health Organization (WHO) Report 2020, annual death from liver disease in Bangladesh is 21,024 or 2.94% of total deaths. About 10 million people have been suffering from hepatitis B and C and 45 million have been suffering from fatty liver disease. So, 1 in every 3 people in Bangladesh have liver disease. Like other countries, noncommunicable liver disease (fatty liver and others) in Bangladesh is increasing, and communicable (HBV, HCV) liver disease is decreasing. Please tell us, in brief, about the prevalence of Viral Hepatitis in Bangladesh? What are your suggestions to create awareness among the common people about Viral Hepatitis? According to the Hepatology Society, Dhaka, Bangladesh, a nationwide popu-

INTERVIEW 83 At least 50 percent of our patients in hospitals are admitted with cirrhosis of liver and some cirrhosis may turn into liver cancer also Prof. Dr. Chanchal Kumar Ghosh Dept. of Gastroenterology BSMMU & Secretary General Bangladesh Gastroenterology Society called Cholangiocarcinoma. And among the liver diseases, there are many diseases like: acute hepatitis caused by hepatitis A, D and E virus, there is chronic hepatitis caused by hepatitis B virus and hepatitis C virus. There is also a more common disease throughout the world including Bangladesh which is Fatty Liver, which is more prevalent now in Bangladesh as well. All of this chronic hepatitis and fatty liver may turn into cirrhosis of liver. Cirrhosis of liver is not uncommon in Bangladesh, at least 50 percent of our patients in hospitals are admitted with cirrhosis of liver and some cirrhosis may turn into liver cancer also. What are the trigger factors and symptoms of Irritable Bowel Syndrome (IBS)? Is it preventable? What changes of diet can help patients with IBS? IBS is a functional disease, there is no evidence of any organic lesion in colon. It is a disease of colon usually caused due to the gut brain axis disorder that is abnormality in the cell-3 pathway from the gut to brain. The trigger factors are: if there is any anxiety or emotional factors or any food which may stimulate or irritate the colon, it may cause IBS. Some infections sometimes may also trigger the IBS. Main symptom of IBS is diarrhea, chronic diarrhea. The characteristic of the diarrhea is frequent motion, especially in the morning and in small amount. Also, there is feeling of incomplete evacuation, but there is no blood in the stool and there is no weight loss or anorexia, as it is not an organic disease. Of course, IBS is preventable and if the patients of IBS maintain or bring some changes in lifestyle, that is if they abstain from the diets like milk and milk like products, spicy foods, junk foods and unhygienic foods etc. Also, the anxiety should be treated. Sometimes, Amitriptyline or SSRI are commonly prescribed antidepressants advised by the physicians to treat anxiety or psychological factor. Sometimes there is infection, and then antibiotics or probiotics are suggested for IBS. Regarding changes in diet, as in the diet that triggers IBS are: of course milk, milk products should be avoided and especially I would like to mention some foods that usually triggers IBS should be restricted. Such as coconut water, leafy vegetables, spicy food, oily food such as biriyani, polao, red meat such as mutton, beef etc. and junk food. Please tell us in brief about Peptic Ulcer Disease (PUD)? How do we treat and prevent recurrence of PUD? PUD is the disease of stomach and duodenum and sometimes the lower part of the esophagus. Mostly, it is due to bacteria, H. pylori/Helicobacter pylori bacteria. Other causes of PUD are painkiller, which is a nonsteroidal anti-inflammatory drug (NSAIDs) like indomethacin, ibuprofen, etc. There are some trigger factors of PUD, such as smoking, alcohol, stress, etc., but the main causes are Helicobacter pylori bacteria and NSAIDs. The symptoms are usually abdominal pain, there is abdominal distension, nausea and vomiting, etc. The management of PUD is treatment of the ulcer and bacteria. In order to treat bacteria and H. pylori, there is some anti-H. pylori regimen like triple therapy or quadruple therapy. In our country there is amoxicillin and levofloxacin based triple therapy with PPI (proton pump inhibitors) or triple therapy with omeprazole, metronidazole and clarithromycin with PPI (proton pump inhibitors) that are usually practiced. In case of NSAIDS, we advise patients to avoid NSAIDs or to take NSAIDs in optimum doses with PPI, and the PPI should be continued for one month to one and a half month. To prevent the recurrence of PUD, it is suggested to take NSAIDs with the advice of a physician or in appropriate dose. Sometimes in old age, some patients need to take NSAIDs like aspirin due to heart disease, such patients should take one PPI along with the aspirin. In case of H. pylori, H. pylori tests like Rapid urease test/Urea breath test/Stool antigen test should be done. If there is presence of H. pylori, proper anti H. pylori medication should be given to treat the H. Pylori. How common is GERD in our country? Can it lead to malignancy? How can Would you please let us know about the gastrointestinal, pancreato-biliary and liver diseases in our country? Gastroenterology is the subject, is the combination of gastrointestinal tract, pancreas and liver. So, gastroenterology contains gastrointestinal diseases, pancreatic diseases and liver diseases. In gastroenterology there are so many diseases, among which the common diseases are: Peptic Ulcer Disease (PUD), Gastroesophageal Reflux Disease (GERD), Malabsorption syndrome, Chronic diarrhea, Irritable Bowel Syndrome (IBS), Ulcerative colitis, Crohn’s disease, Irritable Bowel Disease (IBD), Gastrointestinal cancers, Diverticulitis, Constipation, Malabsorptive diarrhea which is a very serious disease and cancers like Gastric cancer, Colon cancer etc. Among the pancreatic diseases the most common are: Acute pancreatitis, Chronic pancreatitis, Pancreatic tumor, Pancreatic cancer. Among the biliary diseases, there is obstructive jaundice, obstruction by stone diseases and obstruction by biliary malignancy that is

84 INTERVIEW we prevent such complications? GERD is latest in the study and prevalence of GERD in our country is about 11 per cent. So, it is not uncommon, GERD is usually common in some population like obese, those who are obese and those who are in pregnancy and people whose lifestyle is not normal. Such as people who take large meal, drink excess water or habitat to smoking/alcohol. In these groups of people GERD is resultantly strong. In our study, the GERD is more common in female patients. As in our culture, the females usually eat food at late night and after taking meal they go to bed. So, they develop the GERD symptoms. Another cause of GERD is ‘Hiatal Hernia’ and it is also due to the abdominal pressure. But of course, due to GERD there may be esophagitis which may cause Barrett’s esophagus. That is due to repeated exposure to stomach acid, leading to inflammation, damage, and changes in the esophagus epithelium, causing Barrett’s esophagus and eventually esophageal cancer. Thus, GERD may turn into malignancy and that is adenocarcinoma. GERD is an important cause of adenocarcinoma of the lower esophagus. We can prevent such complications by maintaining some lifestyle that is if there is obesity, obesity should be treated and regular exercise at least 45minutes, at least 5 days in a week or eating optimum food. Especially, we have to avoid more carbohydrate or large meals and we have to avoid red meat, fast food, junk food, etc. So, a healthy lifestyle is important to prevent GERD and if there is a history of smoking, then smoking should be stopped, and if there is alcoholism, alcohol should be stopped. If there is hiatal hernia it should be treated as well. Sometimes, there is a need of PPI and longtime PPI and other medications can be advised for patients with acid reflux diseases. Sometimes surgery is needed also. We very often hear about constipation among our population. Actually, what is the reason and management of this common disease? Constipation is common in our society, especially in childhood and in elderly population constipation is more common. That is in elderly population, constipation is common due to there is, for evacuation of stool from the rectum, we need the muscle, that is rectal muscle. When the rectal muscle contact, it pushes the bulk of stool to outside. So in old age, there is weakness of the pelvic muscle and the rectum become unable to push the bulk of stool to outside, so there is constipation. Sometimes there is some systemic reason of constipation like hypothyroidism, hyperkalemia, diabetes etc. Diabetes is an important cause of constipation, in diabetes there is autonomic neuropathy which may cause constipation. Also, sometimes in the debilitated patient, especially in old age, or due to some systemic inside cancer, if the intake of both food and water is less, then there is constipation. There is also constipating type IBS (Irritable Bowel Syndrome), constipated IBS, that usually causes abdominal pain, and especially the constipated IBS group evacuates bowel 2 to 3 times in a week. It is not harmful but sometimes it bothers some patients. The management of the constipation is, what is the cause of the constipation we have to first recognize. If it is in old age patients, we have to recognize if it is due to pelvic muscle weakness. We should advice the patient for pelvic exercise, there are some pelvic exercises and we should advice the patient to take proper food. Especially after heavy breakfast, we advise the patient, if there is a feeling of evacuation, they should go to the toilet and evacuate. And if there is no feeling of evacuation, they should not go and waste time in the toilet. If there is IBS, sometimes it may need some anti-depressants or sometimes some medication like colace, milk of magnesia or many more. Nowadays, many new drugs are available to treat constipation all over the world and it is available in Bangladesh as well. l Exploring Modern Gastrointestinal Diagnostic Techniques # Endoscopic Ultrasound (EUS): Endoscopic ultrasound combines endoscopy and ultrasound to produce detailed images of the gastrointestinal tract and nearby organs. EUS is particularly useful for assessing tumors, cysts, and other abnormalities in the digestive system. # Capsule Endoscopy: Capsule endoscopy involves swallowing a small, pill-sized camera that captures images of the digestive tract as it passes through. This technique is especially valuable for visualizing the small intestine, an area that was previously challenging to access. # Virtual Colonoscopy (CT Colonography): Virtual colonoscopy uses computed tomography (CT) scans to create 3D images of the colon. It’s a less invasive alternative to traditional colonoscopy and is effective in detecting polyps and other abnormalities. # Breath Tests: Breath tests are used to diagnose various gastrointestinal disorders, such as lactose intolerance and bacterial overgrowth. Patients exhale into a device, and the analysis of the breath provides valuable insights into digestive function. # Functional MRI (fMRI): Functional MRI is becoming increasingly valuable for studying gastrointestinal motility and function. It offers dynamic images of the digestive tract in real-time, allowing clinicians to better understand how different organs are working. # Genetic Testing: Genetic testing can provide insights into a person’s predisposition to certain gastrointestinal conditions. It’s also used to personalize treatment plans and predict disease risk. l

85 Globally, gastric cancer is the fifth most common malignancy and the fourth leading cause of cancerrelated death. In a study, a team of researchers reported the first robot-assisted remote radical distal gastrectomy performed using 5G communication technology. The novel procedure was conducted on a 51-year-old patient diagnosed with stage T2N0M0 gastric cancer, utilizing the domestically developed ‘Tuomai’ four-arm laparoscopic robotic surgery system. Notable results include minimal intraoperative delays and no packet loss, highlighting the potential of 5G technology to advance remote surgical procedures. The patient’s quick recovery without complications affirmed the procedure’s safety and effectiveness. l Source: MedicalNews.Net TECHNOLOGY Novel device for stomach complaints is successful in human trial An endoscopic mapping device, developed by scientists consists of an inflatable sphere covered in sensors, delivered down the esophagus and able to measure electrical activity in the gut. Research has found faulty bioelectric gut waves can lead to stomach pain, nausea, vomiting and bloating. But often doctors can’t find out what the problem is. That’s because gut electrics aren’t nearly as strong or as easily measured as heart waves; without surgery it’s hard to know if someone has a so-called ‘dysrhythmia’ gut—and if so, where the problem is. Gastrointestinal researcher Dr. Tim, the head of the team, that has developed the endoscopic sensor device. He says the project has been 10 years in the making and completing the first human clinical trials is a huge step forward. “This is a critical step, taking us from engineering and pre-clinical work to real patients. “It’s very difficult to do, but this is the dream; the pinnacle of bioengineering.” l Source: Medical Express Robot-assisted gastrectomy utilizing 5G communication technology for gastric cancer patients

INTERVIEW 87 Individuals must use PPIs only as prescribed by a Healthcare Professional and for the recommended duration Prof. Dr. Tohidul Karim Majumder Head, Dept. of Gastroliver Sheikh Russel National Gastroliver Institute & Hospital As an eminent Gastroenterologist of the country, would you please let us know about the common pancreaticobiliary disorders and GI malignancies in our country? In Bangladesh, one common pancreaticobiliary disorder is gallstone disease, which includes conditions like cholelithiasis (stone in the gallbladder) and choledocholithiasis (stones in the common bile duct). These conditions often require intervention like ERCP or surgery for management. Acute and Chronic pancreatitis and pancreatic cancer are also prevalent pancreaticobiliary disorders in Bangladesh, although they are less common than gallstone disease. In addition, obstruction of the biliary channel due to bile duct cancer and benign biliary stricture is not uncommon. Early detection and management are crucial for improving outcomes in these conditions. On the other hand, GI cancers are among the common oncological disorders which might include oesophageal cancer, stomach cancer, colon cancer and liver cancer. Factors like smoking, betel nut chewing, H. Pylori infection as well as diet might be associated with GI cancers. It can be noted that apart from GI cancers, Liver and pancreatic cancers are also prevalent in our zone. Hepatitis B and C infections, aflatoxin exposure, and non-alcoholic fatty liver disease are significant risk factors for these cancers. Early detection through screening programs, lifestyle modifications, and access to appropriate treatment facilities are essential for managing these GI cancers effectively in Bangladesh. What are the trigger factors and symptoms of Irritable Bowel Syndrome (IBS)? Is it preventable? What changes in diet can help the patients? Numerous factors can trigger irritable bowel syndrome (IBS). Certain foods, beverages, fatty foods, dairy products, caffeine, alcohol, and artificial sweeteners can trigger symptoms of IBS in some individuals. In addition, emotional stress, anxiety, and infections can also aggravate the symptoms of IBS. Common symptoms of IBS include abdominal pain or discomfort, often relieved by passing of stool, changes in bowel habits, including diarrhea, constipation, or altered bowel habit, bloating, excess mucus in the stool, and feeling of incomplete bowel movements, fatigue and difficulty in sleeping. It’s important to note that symptoms can vary widely among individuals with IBS. IBS is not entirely preventable because its exact cause is not fully understood. However, there are steps individuals can take to potentially reduce the risk of developing symptoms or manage existing symptoms effectively. Of which, dietary modification is most important. Avoiding trigger foods such as certain types of carbohydrates (FODMAPs), dairy, caffeine, and alcohol may help manage symptoms. Sorting out the trigger foods and avoiding those are important. Stress management, regular exercise and maintaining a healthy lifestyle can also help to alleviate the symptoms. Please tell us briefly about Peptic Ulcer Disease (PUD). How do we treat and prevent recurrence of PUD? Peptic ulcer disease (PUD) refers to the formation of ulcers on the inner lining of the stomach, small intestine or oesophagus. The primary causes of PUD include infection with Helicobacter pylori bacteria, long-term use of painkillers such as aspirin or ibuprofen, and excessive alcohol consumption. Symptoms of PUD may include periodic abdominal pain associated with food intake, nausea and vomiting, bloating and feeling full quickly after eating. Treatment for PUD often involves a combination of medication and lifestyle changes. Proton Pump Inhibitors (PPIs) and H2-receptor antagonists can help to reduce stomach acid production which allows ulcers to heal. If H. pylori infection is present, a course of antibiotics, often in combination with PPIs and other medications is prescribed to eradicate the bacteria. Avoiding trigger foods like spicy foods, caffeine, and alcohol can help prevent recurrence. While stress does not directly cause PUD, it can worsen symptoms. Engaging in

INTERVIEW 89 stress-reducing activities such as exercise, relaxation techniques, and counseling may be beneficial. To prevent the recurrence of PUD, it’s essential to complete prescribed courses of antibiotics if H. pylori infection is present. Use NSAIDs only under the guidance of a healthcare professional. Avoid smoking, as it can delay ulcer healing and increase the risk of complications. A balanced diet and a healthy weight should be maintained. Regularly following up with a healthcare provider to monitor ulcer healing and adjusting the treatment is important. Overall, adherence to medication regimens, lifestyle modifications and avoidance of known triggers are crucial for effectively treating PUD and preventing its recurrence. How common is GERD in our country? Can it lead to malignancy? How can we prevent such complications? The prevalence of GERD (Gastroesophageal Reflux Disease) in Bangladesh is not extensively documented, but it is recognized as a common condition in South Asia including Bangladesh. A study shows that 5.5% of the population is suffering from GERD symptoms in Bangladesh. Factors such as diet, lifestyle, and obesity contribute to its occurrence. While GERD itself does not typically lead directly to malignancy, it can increase the risk of developing certain complications that may predispose individuals to oesophageal cancer over time. One such complication is Barrett’s oesophagus, a condition in which the normal lining of the oesophagus is replaced by tissue similar to that found in the intestines. Barrett’s oesophagus is associated with a higher risk of developing oesophageal adenocarcinoma, a type of oesophageal cancer. Preventing complications of GERD, including the development of Barrett’s oesophagus and oesophageal cancer, involves managing GERD symptoms effectively and minimizing acid reflux through lifestyle modifications which include avoiding trigger foods and beverages (such as spicy foods, caffeine, alcohol, and fatty foods), maintaining a healthy weight, avoid smoking, and elevating the head of the bed during sleep can help reduce acid reflux. Medications like Proton pump inhibitors (PPIs) and H2-receptor antagonists can help reduce stomach acid production and alleviate symptoms of GERD. It’s essential to take these medications as prescribed by a healthcare professional. Individuals with GERD should have regular follow-up appointments with their healthcare provider to monitor symptoms and evaluate for any complications, such as Barrett’s oesophagus. Endoscopic screening may be recommended for individuals with longstanding, severe GERD symptoms or other risk factors for oesophageal cancer to detect complications such as Barrett’s oesophagus early. If Barrett’s oesophagus is diagnosed, regular surveillance endoscopy and potential interventions (such as radiofrequency ablation) may be recommended to reduce the risk of progression to esophageal cancer. By effectively managing GERD symptoms and addressing potential complications early, individuals can reduce their risk of developing malignancies such as oesophageal cancer. Being available over-the-counter, patients nowadays are self-prescribing and overusing anti-ulcerant drugs i.e. PPIs. What are the consequences of such irrational use? The overuse and self-prescription of proton pump inhibitors (PPIs), which are antiulcer medications, can lead to several consequences and health risks. Overuse of PPIs can mask underlying conditions or symptoms of more severe gastrointestinal disorders, delaying proper diagnosis and treatment. In addition, PPIs reduce stomach acid production, which plays a crucial role in defending against ingested pathogens. Long-term PPI use has been associated with an increased risk of gastrointestinal infections such as Clostridium difficile (C. difficile) and pneumonia. Stomach acid is essential for absorption of certain nutrients, including vitamin B12, iron, calcium, and magnesium. Prolonged PPI use can lead to deficiencies in these nutrients, potentially causing anemia, osteoporosis, and other health issues. Abrupt discontinuation of PPIs can lead to rebound acid hyper secretion, causing a sudden increase in stomach acid production and exacerbating symptoms such as heartburn and acid reflux. Long-term PPI use has been associated with an increased risk of bone fractures, particularly in older adults, possibly due to impaired calcium absorption and bone metabolism. Prolonged suppression of stomach acid secretion by PPIs can lead to gastric atrophy and reduce stomach acid production, which may increase the risk of gastric cancer and other gastrointestinal complications. PPIs can interact with other medications, affecting their absorption and efficacy. To mitigate these risks, individuals must use PPIs only as prescribed by a healthcare professional and for the recommended duration. Additionally, lifestyle modifications and alternative treatments may be considered for managing gastrointestinal symptoms before resorting to long-term PPI therapy. l New 8 advancements in GI technology l The FDA granted 510(k) clearance to the Pill-Cam Small Bowel 3 system for remote endoscopy manufactured by Medtronic. l MicroTech Endoscopy introduced the Lesion-Hunter cold snare, a polypectomy-advancing cold snare with an ultrathin nitinol wire. l According to a study, patients who received virtual reality video teaching before to a colonoscopy had improved stool preparation, greater polyp and adenoma detection rates, and increased compliance and satisfaction. l Health Canada issued a license to Medtronic for its artificial intelligence endoscopy system, GI Genius. l Virtual Incision has concluded a $46 million series C fundraising round, which will be used to support the MIRA Surgical Platform. l Endo Tools Therapeutics of Belgium received FDA approval for their Endomina system for endoscopic suture application and soft tissue approximation. l Iterative Scopes acquired $150 million in series B funding to develop their gastrointestinal technology powered by artificial intelligence. l Standard Bariatrics’ Titan SGS surgical stapler has been utilised in over one thousand clinical instances. SOURCE: GASTROENTEROLOGY UTILITARIAN CONFERENCES

INTERVIEW 91 l Peptic Ulcer Disease (PUD). l Non-Ulcer Dyspepsia (NUD). l Gastroesophageal Reflux Disease (GERD). l Dysphagia due to Esophagitis (pill induced), GERD, Corrosive, Achalasia cardia, Carcinoma esophagus. l Irritable bowel syndrome (IBS). l Inflammatory Bowel Disease (IBD). l Rectal bleeding due to hemorrhoids/ rectal/colonic polyp, CA rectum/colon. l Chronic constipation. Common Liver related diseases in Bangladesh are: l Acute viral hepatitis. l Chronic viral hepatitis. l Cirrhosis of liver. l Non-Alcoholic Fatty Liver Disease (NAFLD/MAFLD). l Liver abscess (amoebic or pyogenic). l Hepatic malignancy (primary or secondary). l Alcoholic liver disease. l Cystic liver disease. l Wilson Disease, hemochromatosis. Common Pancreatico- biliary related diseases in Bangladesh are: l Cholelithiasis. l Acute cholecystitis. l Choledocholithiasis. l Acute and chronic pancreatitis. l Carcinoma gallbladder. l Carcinoma pancreas. l Cholangiocarcinoma. Please tell us in brief about Peptic Ulcer Disease (PUD)? How do we treat and prevent recurrence of PUD? Peptic Ulcer is a chronic disease affecting up to 10% of the world’s population. Peptic ulcers are defects or breaks in the gastric or small intestinal mucosa that have depth and extend through the muscularis mucosae. In contrast to erosions, which are small and superficial mucosal lesions, peptic ulcers can vary in size from 5 mm to several centimeters and may lead to complications such as GI bleeding, obstruction, penetration, and perforation. The pathogenesis of peptic ulcers is multifactorial and arises from an imbalance of protective and aggressive factors such as when GI mucosal defense mechanisms are impaired in the presence of gastric acid and pepsin. Peptic ulcer disease was long considered an idiopathic and lifelong disorder. Major risk factors of PUD are: l Helicobacter pylori infection, NSAIDs, aspirin use and acid hyper-secretory disorders (e.g. Zollinger-Ellison syndrome), psychological stress, smoking, drinking alcohol. l Medications such as potassium chloride, concomitant use of corticosteroids with NSAIDs, bisphosphonates, selective serotonin reuptake inhibitors, sirolimus, mycophenolate mofetil, 5-fluorouracil. l Chronic liver and kidney diseases, neoplasia, hyperparathyroidism, Crohn’s disease, sarcoidosis, myeloproliferative disorder, systemic mastocytosis. l Other rare infections (e.g. cytomegalovirus, herpes simplex, tuberculosis). l Critically ill patients with severe burns (curling’s ulcer), head injury (cushing’s ulcer), physical trauma, multiple organ failure, etc. Treatment Treatment of peptic ulcers consists of healing the ulcer and preventing ulcer recurrences and future complications. All ulcer patients should be tested and treated for H pylori even if they have a clear history of NSAID or aspirin use. It is not clinically possible to determine whether ulcers arise directly from H pylori, NSAID/aspirin use, or a combination of these factors. Although H pylori and NSAID use cause most ulcers, the level of acid secretion still plays a role in pathogenesis and healing. Multiple studies show that the administration of acid-suppressive medications promotes active ulcer healing. Commonly used drugs are PPI (Omeprazole, Pantoprazole, Esomeprazole, Rabeprazole), Potassium Competitive Acid Blocker (PCAB), Vonoprazan fumarate, Bismuth subciIf GERD is left untreated for over 5 years it proceeds to develop esophageal cancer of the lower end of esophagus Prof Dr. Mohammad Mahmuduzzaman Professor & Head Dept. of Gastroenterology Shaheed Suhrawardy Medical College, Dhaka As an eminent Gastroenterologist of the country, would you please let us know about the Gastrointestinal, Panreaticobiliary and Liver diseases in our country? Gastrointestinal system begins with the mouth and contains esophagus, stomach, small intestine and large intestine, which mainly aid in mechanical digestion of food although the salivary gland and pancreas produce digestive enzymes, ending with the rectum and the anal region. With these other accessory organs that are connected, such as the liver and the gallbladder that produce and store the bile. Common gastrointestinal diseases in Bangladesh are: l Diarrhea and other enteric infections caused by virus, bacteria and intestinal parasites. l Cholera and Bacillary dysentery. l Enteric fever such as Typhoid and Paratyphoid also constitute as a fraction of disorders of gastrointestinal disease.

92 INTERVIEW trate, Bismuth subsalicylate. For eradication of H Pylori, triple therapy is used. In triple therapy antibiotics like Amoxicillin, Metronidazole or Tinidazole, Clarithromycin, Levofloxacin are used. They are given in different combination for 14 days. The eradication rate is significantly affected by the regional variation in H. pylori resistance patterns. How common is GERD in our country? Can it lead to malignancy? How can we prevent such complications? GERD is a common GI problem. The prevalence of GERD in our society is around 20%. In a survey in western community, 25% people suffer from heartburn once a month, 12% suffer once a week and 5% suffer once a day. Gastroesophageal reflux is a physiologic process by which gastric contents move retrograde from the stomach to the esophagus. Gastroesophageal reflux itself is not a disease and occurs multiple times each day without producing symptoms or mucosal damage. In contrast, GERD is a spectrum of disease usually producing symptoms of heartburn and acid regurgitation. GERD is a consequence of the failure of the normal anti-reflux barrier to protect against frequent and abnormal amounts of refluxed material. The pathogenesis of GERD is complex, resulting from an imbalance between defensive factors and the aggressive factors protecting the esophagus. In long-run the mucosa of the esophagus changes into Barrett’s esophagus and subsequently if GERD is left untreated for over 5 years it proceeds to develop esophageal cancer of the lower end of esophagus. GERD is preventable. GERD is related to overweight. If we can maintain the standard body weight, we can prevent the problem. We must avoid foods which may trigger GERD like junk foods, fried foods, spicy foods, milk and milk products, smoking, alcohol and carbonated drinks. There are some etiquettes that we also need to follow, (i.e. avoid eating full stomach meals, avoid over eating, keeping one-third of our stomach empty, avoid eating triggering foods, avoid taking water immediately after meal, avoid going to bed right after eating and wait at least two hours after meal to go to sleep). Some drugs like antihypertensive agents or anti-anxiety drugs may also precipitate this illness. Why Hepatitis B vaccine is not being prescribed to all patients, considering its availability and high risk of chronic infection leading to cirrhosis and liver cancer posed by Hepatitis B virus infections? There are more than 2 billion individuals with serologic evidence of hepatitis B virus (HBV) infection worldwide, and an estimated 250 to 270 million individuals are chronically infected. However, HBV infection can potentially be eradicated through global vaccination. In our country HBV vaccine is included in EPI schedule for many years. In case of mother, who is HBsAg (+ve), HBV immunoglobulin is also given to the new born baby. In our clinical practice we prescribe vaccine against HBV that is given to adults who are HBsAg (-ve)/Anti-HBc (total –ve). We advocate vaccination to healthcare workers, immunosuppressed patients, females trying to conceive, dialysis patients, AIDS patients. We often hear about constipation among our population. Actually, what is the reason and management of this common disease? Constipation is one of the most common gastrointestinal complaints in the general population, with an estimated worldwide prevalence from 12 to 19 percent with a higher prevalence in females. The prevalence of chronic constipation increases with age, most dramatically in patients who are 65 years of age or older. Constipation may occur secondary to metabolic disorders, obstructing lesions of the gastrointestinal tract, endocrine disorders, neurologic disorders, or medications. Chronic Idiopathic constipation may result from a defecation disorder characterized by an inability to coordinate the abdominal and pelvic floor muscles, slow colonic transit, or may be functional without identifiable structural or biochemical cause. Patients with irritable bowel syndrome (IBS) may also present with constipation. The initial evaluation of patients who present with chronic constipation should include a history and physical examination and laboratory studies to identify secondary causes of constipation and alarming features that warrant additional evaluation for organic disease. Alarming features are hematochezia or heme-positive stool, iron deficiency anemia, clinically significant weight loss (>5% of usual body weight over 6 to 12 months), new onset unexplained constipation, lump in the abdomen, obstructive symptoms, family history of colorectal cancer or inflammatory bowel disease. The management of idiopathic chronic constipation includes patient education, dietary changes, bulk forming laxatives, and the use of non-bulk-forming laxatives or enemas. Efficacy, safety, convenience, cost, and clinical response all weigh into the choice of the selected treatment. Management of constipation is not very much straight forward. It should be managed according to the cause of the individual patients. l FAST FACTS As per a recent analysis, high pressure is the cause of more than 240,000 deaths annually in Bangladesh. WHO recommends 05 gram salt intake a day while Bangladeshis consume 09 gram a day. According to recent study, globally, some 1.6 million lives could be saved each year by reducing salt intake by 30 per cent. US citizens on average experience their first heart attack in the age of 60 to 65 years old while it is 51 to 52 years for Bangladeshis and 52 to 56 years for Indians, says a global study. According to a study, Bangladesh has low doctor-patient ratio (about 5.25 doctors per 10,000 populations) less than the global standard (World Health Organization - WHO recommends a doctor to population ratio of 1:1,000). According to a survey, the number of people with diabetic neuropathy has more than tripled globally since 1990, rising to 206 million cases in 2021. As per Bangladesh Bureau of Statistics, heart attack killed 1.02 in every 1,000 in Bangladesh in 2023. Preventing exposure to lead could reduce the burden of idiopathic intellectual disability by 63.1% and reducing high fasting plasma glucose levels could reduce the burden of dementia by 14.6%.

COURSES & CONFERENCES 93 N.B. Dates/Venues of forthcoming events are subject to change/cancellation etc. with or without notice. So, intending participants are advised to check all details relating to VISA and other relevant matters before departure. TITLE VENUE SCHEDULE European Association for the Study of Liver (EASL) Congress 2024 Milano, Italy Jun 05–08, 2024 International Liver Congress 2024 (EASL) Milan, Italy Jun 05–08, 2024 7th Annual World Congress of Digestive Disease 2024 Budapest, Hungary Jun 12–14, 2024 23rd International Conference on Gastroenterology and Digestive Disorders 2024 Roma, Italy Jun 13–14, 2024 British Society of Gastroenterology 2024 Birmingham, UK Jun 17–20, 2024 ESMO Gastrointestinal Cancers Congress 2024 Munich, Germany Jun 26–29, 2024 World Congress on Gastrointestinal Cancer 2024 Barcelona, Spain Jul 03–06, 2024 The 14th Asia-Pacific Primary Liver Cancer Expert Meeting Honolulu, Hawaii July 18–20, 2024 3rd International Conference on Gastroenterology and Liver Amsterdam, Netherlands Jul 25–26, 2024 International Surgical Week ISW 2024 Kuala Lumpur, Malaysia July 25–29, 2024 14th Int’l Healthcare, Hospital Management, Nursing, and Patient Safety Conference 2024 Dubai, UAE July 25–27, 2024 The Liver Week 2024 Seoul, Korea June 27–29, 2024   24th International Conference on Gastroenterology and Hepatology Berlin, Germany Aug 22–23, 2024 International Conference on Surgical Gastroenterology and Liver Transplant Chittagong, Bangladesh Aug 08, 2024   39th World Ophthalmology Congress Vancouver, Canada Aug 16–19, 2024 3rd World Congress on Medicinal Chemistry and Computer-Aided Drug Design Toronto, Canada Aug 27–28, 2024 International Conference on Hepatology 2024 Bogra, Bangladesh Aug 29, 2024   6th Edition of Euro-Global Conference on Pediatrics and Neonatology Madrid, Spain Sept 02–04, 2024 XII Congreso Nacional de Gastroenterología y Endoscopía Digestiva Ciudad de Panama Sept 05–07, 2024 9th International Conference on Future Pharma and Innovations Amsterdam, Netherlands Sept 11–12, 2024 Australian Gastroenterology Week 2024 (AGW2024) Adelaide, Australia Sept 14–16 2024 Mayo Clinic Innovations in Gastroenterology and Hepatology 2024: AI and Beyond Denver, United States Sept 19–21 2024 International Liver Course 2024 Parc Chanot, France Sept 19–21 2024 XVI Congreso Paraguayo de Gastroenterología y Endoscopia Digestiva Asuncion, Paraguay Sept 25–27 2024 United European Gastroenterology (UEG) Week 2024 Vienna, Austria Oct 12–15, 2024 2nd Edition of Global Conference on Gynecology & Women’s Health Maryland, USA Oct 17–19, 2024 “2nd Edition of International Conference on Gastroenterology Baltimore, USA Oct 21–23, 2024 2nd Edition of International Conference on Gastroenterology Baltimore, USA Oct 21–23, 2024 International conference on Gastroenterology and Hepatology (ICGH 2024) Cape Town, South Africa Nov 04–05, 2024 International Conference on Infectious Diseases 2024 Dubai, UAE Nov 20–21, 2024 International Conference on Liver Transplant And Surgical Gastroenterology Chittagong, Bangladesh Nov 25, 2024   7th World Congress of Pediatric Gastroenterology, Hepatology and Nutrition (WCPGHAN 2024) Buenos Aires, Argentina Dec 04–07, 2024

INTERVIEW 95 As an eminent Gastroenterologist of the country, would you please let us know about the common pancreaticobiliary and oncologic disorders of the gastrointestinal (GI) tract in our country? Pancreatico-biliary and oncologic disorders of the gastrointestinal (GI) tract in our country can vary depending on the region and population, but the following are commonly observed: Pancreatico-Biliary Disorders are as following: l Gallstones (Cholelithiasis): Gallstones are a common condition, particularly among middle-aged individuals and women. l Cholecystitis: Inflammation of the gallbladder. l Choledocholithiasis: The presence of gallstones in the common bile duct, which can lead to jaundice, biliary colic, and other complications. l Chronic Pancreatitis: Long-term inflammation of the pancreas, often caused by alcohol abuse, genetic factors, or autoimmune conditions. l Acute Pancreatitis: A sudden inflammation of the pancreas that can be caused by gallstones, alcohol consumption, or other factors. Common Oncologic Disorders of the GI Tract are as following: l Colorectal Cancer: One of the most common cancers of the GI tract, particularly in older adults. l Gastric Cancer: Gastric (stomach) cancer is more common in certain regions. l Hepatocellular Carcinoma (HCC): The most common type of liver cancer, often associated with chronic viral hepatitis (HBV and HCV), NAFLD. l Pancreatic Cancer: A highly lethal cancer with a poor prognosis. What are the trigger factors and symptoms for Irritable Bowel Syndrome (IBS)? Is it preventable? What changes in diet can help the patients? Irritable Bowel Syndrome (IBS) is a common functional gastrointestinal disorder characterized by recurrent abdominal pain or discomfort and altered bowel habits (e.g., diarrhea, constipation, or a combination of both) without any underlying organic cause. The exact cause of IBS is unknown, but it is believed to involve a combination of factors including gut motility, visceral hypersensitivity, altered gut microbiota, and psychological factors. Trigger Factors Several factors can trigger or worsen IBS symptoms such as: l Diet: Certain foods, such as those high in fat, caffeine, alcohol, spicy foods, and artificial sweeteners, may trigger IBS symptoms in some individuals. l Stress: Emotional stress and anxiety can exacerbate IBS symptoms. l Hormonal Changes: Women may experience worsened symptoms during menstruation. l Infections: Gastrointestinal infections can trigger IBS symptoms, particularly post-infectious IBS. l Medications: Some medications, such as antibiotics or nonsteroidal anti-inflammatory drugs (NSAIDs), can trigger symptoms. Symptoms The symptoms of IBS vary among individuals but typically include: l Abdominal pain or cramping that is often relieved by a bowel movement. l Changes in bowel habits like: diarrhea, constipation or alternating between the two. l Bloating and gas. l Mucus in the stool. l A feeling of incomplete bowel evacuation. Prevention and Management While IBS itself may not be entirely preventable, lifestyle changes can help manage and reduce symptoms, such as: l Dietary Changes: Modifying the diet can help alleviate symptoms. Common dietary recommendations include: l Low FODMAP Diet: This diet limits certain types of carbohydrates that can While IBS itself may not be entirely preventable, lifestyle changes can help manage and reduce symptoms Prof. Dr. Md. Razibul Alam Dept. of Gastroenterology BSMMU

96 INTERVIEW trigger symptoms in some people with IBS. l Fiber Intake: Increasing fiber intake may help relieve constipation-dominant IBS, while reducing fiber may help those with diarrhea-dominant IBS. l Avoid Trigger Foods: Identifying and avoiding specific foods that trigger symptoms, such as dairy, gluten, fatty foods, and caffeine, can be beneficial. l Stress Management: Techniques such as meditation, yoga, deep breathing exercises, and therapy can help manage stress and reduce symptom severity. l Regular Exercise: Physical activity can help regulate bowel movements and reduce stress. l Medications: Depending on the predominant symptom, medications such as antispasmodics, laxatives, or antidiarrheal may be prescribed by a healthcare provider. l Probiotics: Some people with IBS may benefit from probiotics, which can help restore a healthy balance of gut microbiota. Please tell us in brief about Peptic Ulcer Disease (PUD)? How common is H. Pylori infection in our country? How do we treat it and prevent recurrence? Peptic ulcer disease (PUD) is a condition in which ulcers form in the lining of the stomach (gastric ulcer) or the upper part of the small intestine (duodenal ulcer). The most common causes of PUD are: l Helicobacter pylori (H. pylori) infection: This bacterium can cause chronic inflammation and damage to the stomach lining, leading to ulcers. l Nonsteroidal anti-inflammatory drugs (NSAIDs): Long-term use of NSAIDs. l Other factors: Less common causes include smoking, alcohol consumption, and stress, which can exacerbate existing ulcers. Symptoms The symptoms of PUD can vary, but common signs include: l Abdominal pain or discomfort, often described as a burning or gnawing sensation l Pain that may improve or worsen with eating l Bloating, belching, and nausea l Indigestion or heartburn l In severe cases, complications such as bleeding, perforation, or obstruction may occur. H. Pylori Infection: This is a significant cause of PUD worldwide. In our country, the prevalence of H. pylori infection may vary depending on factors such as age, geographic location, and socioeconomic status. Bangladesh has the highest frequency of H. pylori infection 86.3% in South East Asia. It is generally more common in developing countries due to factors such as crowded living conditions and poor sanitation. Treatment Treatment of PUD often focuses on eradicating H. pylori infection (if present) and reducing stomach acid to promote healing: l H. pylori Eradication: This typically involves a combination of antibiotics and a proton pump inhibitor (PPI) for 14 days. Confirmatory non-invasive tests are not widely available in our country. So decision of treating may have to be taken on the basis of clinical history and endoscopic findings. l Acid Suppression: Medications such as PPIs or H2 receptor antagonists (e.g., ranitidine, famotidine) reduce stomach acid and help promote ulcer healing. l Avoiding NSAIDs: If NSAIDs are contributing to the ulcer, alternatives such as acetaminophen or other pain relief options may be recommended. l Lifestyle Modifications: Patients may be advised to avoid smoking, limit alcohol consumption, and manage stress to help prevent recurrence. l Monitor for relapse: Patients should follow up with their healthcare provider to monitor for recurrence. l Healthy lifestyle: Adopting healthy eating habits, reducing stress, and avoiding smoking and alcohol can help prevent recurrence. If you suspect you have PUD or are experiencing symptoms, it is important to seek medical advice and receive appropriate testing and treatment. Your healthcare provider can recommend the best course of action based on your individual circumstances. Being available over-the counter, patients now-a-days are selfprescribing and overusing antiulcerant drugs i.e. PPIs. What are the consequences of such irrational use? The overuse and self-prescribing of Proton Pump Inhibitors (PPIs) can have several potential consequences and risks for patients. While PPIs are effective for treating acid-related conditions such as gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD), their long-term and inappropriate use can lead to adverse effects such as: l Nutrient Deficiencies: PPIs can reduce the absorption of certain nutrients, particularly Iron and vitamin B12. This can lead to deficiencies over time and increase the risk of anemia, and other health issues. l Bone Fractures: Long-term PPI use has been associated with an increased risk of bone fractures, particularly in the hip, wrist, or spine. l Kidney Disease: Chronic use of PPIs may be associated with an increased risk of chronic kidney disease and acute interstitial nephritis. l Infections: PPIs can alter the stomach’s acidic environment, which plays a role in preventing infections. This can increase the risk of gastrointestinal infections such as clostridium difficile and respiratory infections. l Rebound Acid Hypersecretion: Abrupt discontinuation of PPIs after long-term use can lead to a rebound increase in stomach acid production, resulting in a recurrence of symptoms and discomfort. l Drug Interactions: PPIs can interact with certain medications, affecting their absorption and efficacy. This includes drugs like warfarin, clopidogrel, and certain antifungal medications. We very often hear about constipation among our population. Actually, what is the reason and management of this common disease? Constipation is a common gastrointestinal complaint that affects people of all ages. It is generally defined as infrequent bowel movements (fewer than three per week), difficulty passing stool, or a sensation of incomplete evacuation. The causes of constipation are varied and can be due to lifestyle factors, medical conditions or medications. Causes l Dietary factors: A low-fiber diet and inadequate fluid intake are common causes of constipation. l Lack of physical activity: A sedentary lifestyle can contribute to slower bowel movements. l Medications: Certain medications, such as opioids, antacids containing aluminium or calcium, and some antidepressants can cause constipation. l Medical conditions: Conditions such

INTERVIEW 97 as hypothyroidism, diabetes, irritable bowel syndrome (IBS), and neurological disorders can lead to constipation. l Age: Older adults may experience constipation due to a decrease in gut motility, changes in diet and lifestyle or certain medications. l Pregnancy: Hormonal changes and pressure on the intestines during pregnancy can lead to constipation. l Structural or Anatomical issues: Conditions such as bowel obstruction or strictures can cause constipation. l Ignoring the urge: Delaying bowel movements can disrupt regular bowel habits and contribute to constipation. l GI malignancy Management Management of constipation often involves a combination of lifestyle changes and, if necessary, medications such as: l Dietary changes: Increasing dietary fiber intake can help soften stools and promote regular bowel movements. Foods high in fiber include fruits, vegetables, whole grains, and legumes. l Hydration: Drinking plenty of water can help keep stools soft and easier to pass. l Physical activity: Regular exercise can stimulate intestinal function and promote bowel movements. l Establishing a routine: Encouraging regular bathroom habits, such as going to the bathroom at the same time each day, can help establish a consistent routine. l Medications: In some cases, over-thecounter laxatives (e.g., fiber supplements, osmotic laxatives, stimulant laxatives) may be necessary to relieve constipation. Always follow the recommended dosages and consult a healthcare provider for guidance. l Biofeedback Therapy: For some individuals with pelvic floor dysfunction, biofeedback therapy may help retrain the muscles involved in bowel movements. l Addressing underlying causes: If constipation is caused by an underlying medical condition or medication, treating the condition or adjusting the medication may resolve the constipation. l Merck & Co $30.5bn Roche $15.56bn (CHF 14.20bn) Johnson & Johnson $15.09bn Novartis $ 11.37bn AstraZeneca $10.94bn Pfizer $10.58bn Eli Lilly $9.31bn Bristol Myers Squibb $9.21bn AbbVie $7.68bn Sanofi $7.18bn (EUR 6.73bn) 1 Eli Lilly LLY $578.3B US 2 Novo Nordisk NVO $452.8B Denmark 3 Johnson & Johnson JNJ $377.7B US 4 Merck MRK $263.9B US 5 AbbVie ABBV $261.2B US 6 Roche ROG.SW $222.4B Switzerland 7 AstraZeneca AZN $212.2B UK 8 Novartis NVS $201.1B Switzerland 9 Pfizer PFE $181.3B US 10 Amgen AMGN $152.0B US TOP 10 GLOBAL PHARMACEUTICAL COMPANIES The top pharmaceutical companies by R&D expenditure in 2023 Source: Visual Capitalist Source: Global Data GLOBE SCAN

INTERVIEW 99 As an eminent Gastroenterologist in the country, would you please let us know about the Gastrointestinal, Pancreaticbiliary, and Liver diseases in our country? Gastrointestinal, liver, and pancreatic diseases are very common in our country. Overcrowding, poor sanitation, lack of pure water and adulteration of foods are all responsible for this high incidence & prevalence. People frequently suffer from acute diarrhea, dysentery, and jaundice. As estimated, 10-12% of people suffer from Peptic Ulcer Disease (PUD), 15-30% suffers from Gastroesophageal Reflux Disorder (GERD), 10-15% suffers from IBS, and 25-30% of people suffer from fatty liver. A large number of people are also affected by chronic liver diseases, especially by hepatitis B and hepatitis C virus. Acute and chronic pancreatitis is also increasing. Similarly, gastrointestinal cancer, especially stomach & colon cancers, liver & pancreatic cancers are also increasing. What are the trigger factors and symptoms of Irritable Bowel Syndrome (IBS)? Is it preventable? What changes in diet can help the patients? Trigger factors of IBS are: (i) Food & drinks such as milk & milk like products containing lactose, foods containing gluten like wheat, foods & drinks containing artificial sweeteners like aspartame & fructose, fresh fruits especially citrus fruits & salad. (ii) Stress, anxiety, depression & post-traumatic stress disorders (PTSD). (iii) Gut infections following acute diarrhea. (iv) Pregnancy & menstruation. (v) Antibiotics & other medications. Symptoms of IBS are mainly: Alteration of bowel habits, abdominal pain & cramps, diarrhea or passage of mucoid stool, and constipation. Is IBS preventable: No, because in IBS no single or definite cause is identified. But in most cases, symptoms can be controlled by avoiding trigger food & drinks, taking regular exercise, and avoiding stressful conditions. Diet for controlling IBS: IBS is a complex disorder, no single food or drinks are identified that may trigger IBS symptoms. Rather, the patient is asked to enlist foods and drinks that cause problems to him/ her. Those foods or drinks should be eliminated from the dietary menu. Please tell us in brief about Peptic Ulcer Disease (PUD). How do we treat and prevent the recurrence of PUD? Peptic ulcers are breaks or defects in the gastric and intestinal mucosa. Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) are two common causes of PUD. Usually patients with peptic ulcer present with episodic pain, heartburn, nausea, or changes in appetite. Some patients may present with complications like bleeding, perforation, and gastric outlet obstruction. Peptic ulcer disease is mostly tested and confirmed by upper GI endoscopy. A peptic ulcer can be treated by eradicating helicobacter pylori usually by triple therapy, avoiding NSAIDs if possible or multiple NSAIDs, using Cox2B inhibitors, and where necessary using PPI or H2 receptor blocker or vonoprazan. Recurrence of peptic ulcer can be prevented by hygiene maintenance, avoiding NSAIDS,or using safer NSAIDs,paracetamol, or Cox2B inhibitors as mentioned earlier. Avoid smoking and alcohol consumption, as well. How common is GERD in our country? Can it lead to malignancy? How can we prevent such complications? The incidence of GERD is increasing in our country. Approximately 15-30% of people in our country are suffering from GERD. Yes, GERD can lead to malignancy. Following exposure of gastroduodenal contents to lower esophageal mucosa may transform squamous cells into columnar cells. Dysplastic change may occur which ultimately forms into Frank Adenocarcinoma. GERD can be prevented by avoiding foods & acid-containing beverages, avoid lying down for 3 hours after eating, having smaller and more frequent meals, stop smoking and consumption of alcohol, avoid Estimated, 10-12% people suffer from PUD, 15-30% from GERD, 10-15% from IBS, & 25-30% suffers from Fatty Liver Dr. Md. Saif Uddoula Associate Professor & Head Dept. of Gastroenterology Sir Salimullah Medical College & Mitford Hospital