It was a quiet holiday for me this year. Unlike many who travelled during the December school holidays and especially over the long weekends of Christmas and New Year, I stayed in Singapore.

Christmas and New Year day were no different from any weekend – seeing patients during morning ward round and answering calls as they came in during the day.

Clinic was closed for the public holiday.

Then, in the late afternoon of New Year’s Day, the resident medical officer at the hospital emergency room called, asking if I was prepared to accept a new patient who had a history of metastatic breast cancer.

Cynthia, a 66-year-old American, was travelling with her daughter and family from San Diego California, and they were planning to spend a few days in Singapore before heading to Bali.

However, during the flight, the patient suddenly developed severe abdominal pain. Upon arrival at Changi Airport, her daughter who had studied in Singapore, immediately brought her to Mount Elizabeth Hospital.

I met Cynthia at the emergency room, she was lying on a trolley bed and in obvious distress.  When I palpated her abdomen gently, she complained of severe pain throughout the entire abdomen.

An abdominal x-ray showed that there was free gas under the diaphragm.

As any medical student would know, “free gas under the diaphragm” is bad news. The gas in the abdomen should always be confined within the bowels. The fact that there was free gas meant that the must be a hole in some part of the gastro-intestinal (GI) tract.

GI perforation results in discharge of gas as well as other intestinal contents into the abdominal cavity. The spillage of gastric content and faecal material often leads to serious life-threatening infections.

An urgent CT scan confirmed our fears that there was indeed a perforation. I immediately called in Dr Wong Sin Yew who is a specialist in Infectious Disease and Dr Melvin Look who is a GI surgeon.

Cynthia had been on active treatment for her metastatic breast cancer since September of 2013.  She had been receiving chemotherapy weekly for three weeks followed by a one-week break, continuously for 15 months.

The patient suffered hardly any side-effects from her treatment except for a bout of severe diarrhea which occurred just before Christmas. As her symptoms quickly subsided with treatment, she was deemed fit to fly for her vacation.

As a general rule, patients need to have emergency surgery whenever there is evidence of GI perforation. The surgeon would open up and explore the abdomen. He would clean up the “muck” inside the abdominal cavity, try to find the exact site of the perforation and either patch it up or resect that segment of the perforated bowel.

However, surgery was deemed unwise for Cynthia for two reasons. The first concern was her low white blood cell count, because she had just received her chemotherapy a few days before her flight.

This would affect her ability to fight the infection. The other concern was the fact that she had been on Avastin ®. The use of this drug has been associated with perforation of the GI tract in about 3 per cent of patients. The advice is that GI surgery should be avoided for six weeks after its administration. Otherwise, there would be an increased risk of poor wound healing resulting in further perforations.

After careful deliberation, the consensus was to treat Cynthia conservatively with aggressive antibiotics, intravenous feeding and allowing the bowels to rest.

Thankfully, Cynthia is slowly making good progress and the latest CT scans show that the free gas has resolved.

But the road to recovery is going to be a long one.

Our priority is to get her well enough to return her back to the medical team in San Diego. Her intended vacation on the sunny beaches of Bali will have to wait till she recovers well enough to travel again.

The question for patients whose equilibrium of life is upset by complications from treatment is this – what would they have done differently?

Should Cynthia have travelled for holidays? With her compromised immune system, should she have taken the chance of being on such a long flight? Or should she have stayed at home, and have a quiet New Year?

The scenario is more poignant for cancer patients. Their time is limited, so each minute is more precious but their risks are higher so what they choose to do is also limited.

The making of this choice must be up to the patient. As a doctor, I always encourage patients to live life to the full, but they must be the only judge about whether this means taking a small risk or playing it safe.

Dr Ang Peng Tiam



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