Abdominal Distension—An Unexpected Gift


Ching Soong Khoo, MD, MRCP (UK)

Perm J 2017;21:17-026 [Full Citation]

E-pub: 07/11/2017

Abdominal Distension

“Doctor, there’s a lady with abdominal distension.”

“Certainly, please ask her to see me,” I replied.

It was a scorching day at a district clinic in Phnom Penh. The sun blazed down on us with stifling heat. I was one of a group of 20 volunteers from various strata of Malaysian society, including medical and dental students, laboratory technicians, clinicians, and administrative staff. We were volunteering in a health-screening program to deliver care in one of the marginalized communities in Phnom Penh.

As the patient entered the room, I smiled and tried to build rapport with her, using my limited Cambodian vocabulary. She was a Cambodian woman in her late 20s. Apart from looking malnourished with a vague mass at the umbilical level, her physical examination was grossly unremarkable. Because of her presenting concern of the abdominal mass, I recommended an abdominal ultrasound. Although initially apprehensive, she agreed to the scan once the translator (a local student) persuaded her.

“That is a baby!” I swiftly showed her the fetal heartbeats on the scan. Her eyes immediately welled up with tears of joy—relieved that the swelling in her tummy wasn’t something more sinister. Furthermore, she had hoped for a baby since her marriage 6 months earlier. Being underprivileged with limited access to health care services, she had felt helpless and frightened by her abdominal distension. The news of her pregnancy was an unexpected gift of joy to her. I reviewed her vital signs and discovered that her blood sugar level was low at 3.3mmol/L. While I was working out a plan for her antenatal follow-up and low blood sugar, the local student translator reassured me, “Doctor, it is common to see people with low blood sugar in our community.” True indeed, I had seen a few adults earlier at this clinic with low blood sugar and unknown past medical history.

Cambodian History and the Results of Genocide

The day before I began my medical volunteering program, I visited the Tuol Sleng Genocide Museum in Phnom Penh, which chronicles the terror of the Khmer Rouge and Cambodian genocide. The Nobel Laureate Pearl S Buck is often quoted as saying, “If you want to understand today, you have to search yesterday.” I was profoundly affected by the history of Cambodia I learned during my visit to the museum. Cambodia had been wobbling with political turmoil not long after independence was gained in the year 1953. From 1975 to 1979, the Khmer Rouge regime devastated Cambodia completely: paralyzing the economy, decimating the cultures and traditions, destroying the health care system, increasing poverty and famine levels, and killing and torturing hundreds of thousands. More than a million (21% of the population) were estimated to have perished in this Cambodian genocide.1 Cambodia was placed under a state of international embargo for almost a decade after the fall of the Khmer Rouge. In the 1990s, financial support for extensive reconstruction of Cambodia was granted from international and nongovernmental organizations.

Today, Cambodia is classified by the World Bank Group as a lower middle-income country.2 With sustained efforts between the government and the international organizations to rebuild and reform health care services, Cambodia has made significant progress in health status. However, there are still major ongoing challenges. Inequities in access to and utilization of health care remain profound owing to wide gaps in socioeconomic status and geographic distribution. There is a diversified health system in Cambodia in terms of service providers, ranging from local qualified physicians, physicians from nongovernmental organizations, and private care providers to traditional healers. Though poorly regulated, patients turn to private care providers for curative care, whereas the public sector is primarily responsible for preventive care. Use of the public health care services is low because of the poor infrastructure, low staff numbers, inaccessibility in some rural regions, and lack of staff motivation. Reform in health care financing remains a challenge because expenditures on health services are accounted for by household out-of-pocket payments, which are paid overwhelmingly to the private sector.

Women’s health is one of the most exigent issues in Cambodia. Women suffer greatly from the effects of poverty: poor access to education, physical abuse and violence, sexual exploitation, inaccessibility to health care, malnutrition, communicable diseases, unwanted pregnancies, and high maternal morbidity and mortality. Despite a dramatic decline, Cambodia’s maternal mortality ratio remained high at 250 deaths per 100,000 live births in 2010.3 Women from remote communities have little access to antenatal care. The major challenges in those areas include poor sanitation, inadequate supply of safe drinking water, lack of skilled midwives and obstetricians. Lack of transportation and financial assistance is a barrier to seeking antenatal care. Cultural beliefs, which emphasize the use of traditional practices and dissuade pregnant women from seeking antenatal care and support from qualified birth personnel during delivery, are dominant in the rural areas. Many women must turn to abortions and to deliveries in unsafe conditions. Unmet demand for family planning and birth spacing remains high because there is poor availability of and access to contraceptive options.

An Unexpected Gift

Those above-mentioned issues explained precisely how a pregnancy would go undetected in Cambodia. My patient’s situation was just the tip of the iceberg.

My patient stood up from the couch and thanked me. I attempted my very best to provide her with antenatal education via the translator. Feeling reassured, she left the consultation room with an appointment card. I prayed for her. I hoped that she would deliver a healthy baby in the future without complications.

“Next patient, please.” After regaining my composure, I continued to see patients, many of whom had been enduring long waits.

“Doctor, another lady with abdominal distension,” the triage student/assistant said, passing me the case note.

“Sure, my pleasure,” I replied smilingly.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

How to Cite this Article

Khoo CS. Abdominal distension—An unexpected gift. Perm J 2017;21:17-026. DOI: https://doi.org/10.7812/TPP/17-026.

1.    Cambodian genocide program [Internet]. New Haven, CT: Yale University Genocide Studies Program; 2017 [cited 2017 May 31]. Available from: http://gsp.yale.edu/case-studies/cambodian-genocide-program.
2.    World Bank country and lending group [Internet]. Washington, DC: The World Bank Group; 2017 [cited 2017 May 31]. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.
3.    Annear PL, Grundy J, Ir P, et al; Asia Pacific Observatory on Health System and Policies. The Kingdom of Cambodia health system review. Health Systems in Transition 2015;5(2).


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