At the age of 42, a senior executive with a demanding schedule began experiencing persistent discomfort in his upper abdomen.
It wasn’t severe, but it was constant – a dull, nagging sensation that seemed to worsen after meals and linger into the night.
Like many Malaysians, he called it “gastrik”.
He tried over-the-counter antacids.
Then stronger medications prescribed at a clinic.
When the symptoms refused to settle, he did what most patients in his position would do: he underwent an endoscopy.
He went into the procedure anxious, but hopeful. This surely would provide answers.
The result?
“Everything looks normal.”
It was meant to be reassuring.
But instead, it marked the beginning of a different kind of struggle.
Unseen, but present
In modern medicine, a “normal” endoscopy is often considered good news.
It rules out serious conditions, e.g. ulcers, cancers and significant inflammation.
From a clinical standpoint, it is a success.
But for a subset of patients, normal results do not bring closure; they bring confusion.
Because the symptoms are still there.
One of the quiet challenges in gastrointestinal medicine is the gap between what we can see and what patients feel.
Endoscopy is an excellent tool for detecting structural disease, i.e. problems that can be seen with the naked eye.
But not all disorders of the gut leave visible marks.
Conditions such as functional dyspepsia or irritable bowel syndrome (IBS) are real, often debilitating, yet invisible on routine investigations.
The gut, it turns out, can malfunction without being visibly damaged.
This is where the language of medicine sometimes fails patients.
When doctors say, “There is nothing wrong”, what they often mean is, “There is nothing structurally abnormal”.
But what patients hear is something very different, i.e. “Your symptoms are not real.”
The distinction is subtle, but deeply important.
Uncertainty a burden
For the 42-year-old executive, the days following his “normal” result were not reassuring.
At first, there was relief: no cancer, no ulcer, nothing serious.
But as the discomfort persisted, relief gave way to doubt.
If the test was normal, why was he still in pain?
Was something missed? Should he repeat the test?
Was it something he ate? Was it stress?
He began to monitor every sensation.
Every meal became a potential trigger.
He searched online, scrolling through forums and medical websites late into the night.
Each new piece of information brought more questions than answers.
Over time, the uncertainty became its own burden.
This is the hidden cost of a normal endoscopy: not financial, but psychological.
Patients may begin to question their own bodies.
Some embark on cycles of repeated consultations, seeking second or third opinions.
Others experiment with restrictive diets, supplements or alternative therapies in search of relief.
A few may be told, directly or indirectly, that their symptoms are “just stress”.
While stress can indeed influence gut function, the phrasing matters.
To a patient already struggling with unexplained symptoms, such statements can feel dismissive. Reassurance without explanation is rarely comforting.
Intricately interconnected
The reality is that the gut is not an isolated organ.
It is deeply connected to the brain through what is known as the brain-gut axis – a complex communication network involving nerves, hormones and immune pathways.
This connection means that the gut can be exquisitely sensitive.
In some individuals, normal digestive processes – such as the stretching of the stomach after a meal – can be perceived as discomfort or pain.
This phenomenon, known as visceral hypersensitivity, does not show up on scans or scopes, but it is very real.
In other cases, subtle disruptions in gut motility or microbiota may contribute to symptoms, again without visible abnormalities.
In short, a “normal” test does not mean the absence of a problem.
It means the problem lies beyond what the test can detect.
In Malaysia, this issue is further complicated by cultural expectations.
“Gastrik” is a familiar term, often used to describe a wide range of upper abdominal symptoms.
Many patients expect that an endoscopy will provide a definitive answer – a visible cause that can be treated and resolved.
When that expectation is not met, frustration can follow.
Family members too, may unintentionally minimise the experience.
“The doctor said nothing is wrong,” they might say. “Why are you still worried?”
But for the person experiencing the symptoms, the discomfort is not imagined.
It affects appetite, sleep, mood and daily functioning.
Invisible illness is still illness.
How doctors communicate
For doctors, these situations are not straightforward either.
There is a natural tendency to reassure when serious disease has been excluded.
After all, that is an important outcome.
But reassurance alone is often insufficient.
What patients need is not just the absence of bad news, but the presence of an explanation.
They need to understand why they feel the way they do, even if the cause is not visible on a screen.
This requires a shift in how we (doctors) communicate.
Instead of saying “There is nothing wrong”, we might say, “Your test shows no serious disease, which is good. But your symptoms are real, and they may be due to how your gut is functioning rather than how it looks.”
This small change in language can make a significant difference.
There is also a broader reflection to be made about modern medicine.
We have become very good at detecting diseases.
Advances in imaging, endoscopy and laboratory testing allow us to identify abnormalities with remarkable precision.
But when tests are normal, we are sometimes less equipped to guide patients through uncertainty.
In these moments, medicine becomes less about diagnosis and more about interpretation, reassurance and partnership.
It requires time, empathy and an acknowledgement that not all suffering can be neatly explained.
Journey to clarity
As for the 42-year-old executive, his journey did not end with his endoscopy.
With time – and better understanding – he began to recognise patterns in his symptoms.
Stress played a role, but it was not the whole story.
Adjustments to his eating habits, sleep and work schedule helped.
More importantly, having his symptoms acknowledged as real made a difference.
He did not have a dramatic diagnosis.
There was no single treatment that made everything disappear.
But he had something else: clarity.
A normal test result is, in many ways, a success.
It rules out the worst possibilities. It provides a degree of safety.
But it is not always the end of the story.
For some patients, it is the beginning of a different journey – one that is less visible, but no less important.
In medicine, we often search for what can be seen, measured and named.
Yet, some of the most challenging conditions are those that exist in the space between normal results and persistent symptoms.
Perhaps the goal then, is not always to find something.
But to ensure that even when we do not, patients do not feel lost in the absence of answers.
Because sometimes, the hardest diagnosis to live with is not a serious disease, but being told there is nothing wrong when something clearly is.
Dr Khairul Najmi Muhammad Nawawi is a consultant gastroenterologist and hepatologist. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
