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Dr Megan Rossi The gut health specialist on the importance of dietary management
NORMA MCGOUGH
Why you may unknowingly have coeliac disease. P6 BOWEL CONTROL
The ultimate taboo symptom to report to your doctor. ONLINE
PHOTO: MEGAN ROSSI
Europe’s Leading Gastroenterology Meeting October 20–24, 2018 Vienna, Austria www.ueg.eu/week
at UEG Week
“She was an inspiration and my best friend. Pancreatic cancer has taken her away.”
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Mr Nick Battersby on weighing up the risks of treatment for bowel function
Dr Richard Stevens looks at new screen tests for bowel cancer
Boosting your gut health - Dr Megan Rossi’s top 10 tips to enhance your overall health and wellbeing
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Advancements in technology improve diagnosis procedures and treatment solutions Early recognition and treatment reduces not only the burden of symptoms, but also the potential to develop long-term complications says Dr Anton Emmanuel.
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y the age of 40, one in ten Britons has a chronic gastrointestinal illness. Whilst most of these are benign, it is clear that early recognition and treatment reduces not only the burden of symptoms, but also the potential to develop long-term complications. The NHS introduced a landmark early detection scheme, the UK Bowel Cancer Screening Programme in 2007 in England and Scotland. This has been complemented by a one-off screening test involving examination of the bowel with a flexible camera (endoscopy), from the age of 55, and has resulted in reduction of the risk of developing bowel cancer
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by a third. This sort of change in the course of an all too common disease is a striking example of what can be achieved by searching for a diagnosis proactively, and by the technologydriven changes in endoscopy. Such technology-driven advances have been seen in many aspects of gastroenterology. This is highlighted by the use of blood and stool tests to diagnose and monitor conditions like coeliac and inflammatory bowel disease, which previously needed endoscopy and x-ray imaging. Technological advances are also changing treatments – from the new tailored approaches to curing hepatitis C infection to nerve stimulation
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Dr Anton Emmanuel Council Member of the British Society of Gastroenterology and Academic Neurogastroenterologist, University College London
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technology to treat chronic bowel symptoms. Technology continues to evolve. Endoscopic therapies are emerging as alternatives to surgery for common oesophageal problems like heartburn and reflux. Pre-cancerous lesions in the gullet can be targeted by radio-frequency energy delivered via the endoscope. New, endoscopic techniques (“narrow band imaging”) provide detailed views of the intestinal lining that allows highly targeted specimens to be taken from suspicious areas.” The key message is to come forward with your gut symptoms and not sit on them.
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Dr Richard Stevens Chair, Primary Care Society for Gastroenterology
New bowel cancer screening tests save more lives Bowel cancer claims around 15,900 lives in the UK annually. Screening programmes save lives – and new, more effective, screening tests make it easier to take part.
“Screening reduces the risk of dying from bowel cancer by about 15per cent” says Dr Richard Stevens, Chair of the Primary Care Society for Gastroenterology. “Over nine in ten people diagnosed at its earliest stage survive for five years or more, but less than one in ten survive when diagnosed at the latest stage.”
More screening saves more lives Test kits to detect blood in three samples of poo (potentially an early symptom) are posted to everyone, between 60 and 74 every two years. However, says Stevens, “Many people find it distasteful, which is one of the reasons that takeup is just under 60 per cent. Higher-risk groups are among the lowest uptakers.” A new home screening test, coming in 2018, requires only one sample. Trials show it increased uptake by per cent. A new test, called bowel scope, will be offered to everyone aged 55 in England. It involves a single out-patient hospital visit to find and remove any bowel polyps that can develop into cancer. “Bowel scope can reduce the risk of developing bowel cancer by a third, and the risk of dying from it by over 40 per cent,” says Stevens.
Getting the message across Increasing uptake means getting the message across frequently in different ways and languages, says Stevens. “Advertisements about screening, using acceptable words like ‘poo’, help normalise discussion about bowel symptoms, and we are encouraging primary care staff to become bowel screening champions. “Screening may mean embarrassment and discomfort today but it reduces the chance of cancer in the future.”
Cirrhosis deaths: more action is needed now By Linda Whitney
dilated blood vessels in the oesophagus or stomach, resulting from high blood pressure caused when blood is diverted from the damaged liver. There are treatments for varices, but if they rupture and bleed, it can be life-threatening.
Deaths from liver disease are soaring and people in deprived areas are at far higher risk. Now doctors are calling for more action to cut the death toll.
Over the last decade,UK deaths from liver disease have soared by 40 per cent. It is the only major cause of mortality and morbidity which is increasing in England. Meanwhile, in some European countries, liver disease deaths have reduced by 45 per cent. What is the UK doing wrong? “A report recently released by Public Health England identifies the cause of the rise – and it is, in effect, poverty and lack of adequate information,” says Professor Massimo Pinzani, Professor of Medicine, clinical hepatologist, Director of the UCL Institute for Liver and Digestive Health and the Sheila Sherlock Chair of Hepatology at UCL. The PHE data reveals stark inequalities: the rate of people dying early from liver disease in some parts of England is almost eight times higher than in others. In the most deprived fifth of the country, people with liver disease die nine years earlier than those in the most affluent fifth. Moreover, people are dying of liver damage younger - the average age of death is now in the mid 50s. Most causes are preventable Ironically, the vast major-
Professor Massimo Pinzani Professor of Medicine, University College London and Sheila Sherlock, Chair of Hepatology, Director, UCL Insitute for Liver and Digestive Health
ity of liver disease is preventable. Three major risk factors - alcohol, obesity and Hepatitis B and C – account for the large majority of cases. “People with viral hepatitis B and C who live in areas with less effective NHS primary care consequently end up in hospital with advanced chronic liver disease,” says Pinzani. “Meanwhile fatty liver disease, associated with obesity, and alcohol-related liver disease are on the increase and we are seeing increased demand for liver transplants for people in their 20s.” The number of deaths from liver disease also includes about 30-40 per cent of patients with liver cirrhosis developing liver cancer, which greatly accelerates the progression to liver failure. Others die from other conditions caused by cirrhosis, such as bleeding varices. These are
Calling for action An experimental project supported by the British Association for the Study of the Liver is planning preventive action. The plan is to provide GPs in selected areas with a Fibroscan device, which can detect noninvasively the presence of cirrhosis in its early stages,” says Pinzani. He also hails the addition of hepatitis B to the six-in-one vaccination which is routinely offered to all new-borns, due to start this month. “We also need to find a treatment that kills the hepatitis B virus. Current treatments repress its effects, but do not eliminate it. New antiviral treatments that completely eradicate the hepatitis C virus are being rolled out now, starting with patients who have the most advanced disease. Treatment will gradually be extended to those at earlier stages so that should avoid them developing cirrhosis. “We need to find treatments that deliver the same results for hepatitis B.” Read more on healthawareness. co.uk
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New dialysis technology could cut cirrhosis deaths By Linda Whitney
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A new dialysis technology, being trialled in Europe and the UK now, could cut the death toll from cirrhosis. If successful it could be available by 2020.
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y 2020 a new dialysis technology could be available and extend the lives of people with cirrhosis long enough for their liver to start recovering or to find a donor for a liver transplant. The ALIVER consortium has begun to test innovative DIALIVE technology, which was invented at UCL and produced by Yaqrit. The ALIVER project has received funding from the European Union’s Horizon
Rajiv Jalan Professor of Hepatology, Institute for Liver and Digestive Health, Division of Medicine, University College London and Honorary Consultant, Royal Free Hospital.
2020 research and innovation programme after 25 years of experimental research and data collection on extracorporeal perfusion as a therapy option in liver failure. Liver dialysis could have a major impact: at present the incidence of cirrhosis in the UK is increasing, with alcohol-related liver disease and non-alcoholic fatty liver disease fast
becoming the commonest causes. Within five years of the occurrence of cirrhosis, about 50% patients are admitted to hospital with liver-related complications such as infection, bleeding in the gullet, accumulated fluid in the abdomen or confusion. Currently many people with cirrhosis do not realise it, and in 40 per cent of cases are only diagnosed in A&E. Jalan says: “About 30 per cent of those develop acute or chronic liver failure, characterised by the failure of one or more organs such as the liver or brain, and about 30 per cent will die within 28 days of hospital admission. About 40 per cent die within three months.” “The new DIALIVE technology could change the outlook for patients with cirrhosis for whom there is currently little specific treatment except supportive therapy,” says Rajiv Jalan, Professor of Hepatology at the Institute for Liver and Digestive Health, Division of Medicine,University College London and Honorary Consultant at
the Royal Free Hospital. DIALIVE incorporates two filters aimed at removing the toxins that accumulate in patients with liver failure. “The theory is that this should enable the liver to regrow, or keep the patient alive long enough for a liver transplant,” says Jalan. Two clinical trials will now asses its safety and efficacy. Provided its safety trial succeeds, its efficacy will be tested in six locations in Europe including London, Nottingham and Birmingham. Jalan says: “Trial participants will be selected by doctors, but patients (and their families) can ask to be considered for inclusion.” This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 733057.
Read more on www.aliver.info @aliver_eu
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Have you got undiagnosed coeliac disease? By Linda Whitney
Mr Nick Battersby Pelican Cancer Foundation Research Fellow and Surgical Registrar in Colorectal and General Surgery
Guiding treatment decisions in bowel cancer More people are living beyond bowel cancer. A new predictive tool is helping patients assess the benefits of treatments against the likely effects on their lives.
“In celebrating increased survival, we can overlook the effects of treatment on people’s lives, which can be prolonged and devastating,” says Nick Battersby, Pelican Cancer Foundation Research Fellow and Surgical Registrar in Colorectal and General Surgery. Surgery close to the rectum can result in bowel function problems such as incontinence, urgency and clustering (going frequently in a short period). . “This can mean unexpectedly dashing to the toilet and always needing to know where the loo is, which can have a huge impact. Some people never leave home.” says Battersby. The risk of these effects rises when radiotherapy is used as an adjunct to surgery. “With surgery alone, the risk of bad bowel function is about 45 percent, but with radiotherapy too, that rises to 66 per cent,” he says. Sometimes treatment options are clearcut, but in other cases, patients must weigh up treatment benefits against the risk of bad bowel function later. The new POLARS predictive system, devised by Battersby, expresses the risk of poor bowel function in numerical form. “Knowing the likely effects of their choice helps patients give genuinely informed consent, and enables them to start mentally preparing for life after surgery, and we can discuss strategies to mitigate post-operative effects of treatment, ” says Battersby. “It may also protect doctors by providing quantified evidence of informed consent.” Read more on healthawareness.co.uk
beforehand, or risk a false negative” says McGough.
Half a million people in the UK have coeliac disease but don’t know it. Here is how to check if you may be one of them – and why you should ask your GP for a test.
“Over half a million people in the UK have undiagnosed coeliac disease,” says Norma McGough, Director of Policy, Research and Campaigns at Coeliac UK, the national charity for people needing to live gluten free. “Diagnosis takes on average 13 years and commonly people go undiagnosed until middle age or older, despite many GP visits. That is why we want to increase awareness of coeliac disease among primary care professionals as well as the public.” One of the problems is that the symptoms are common to many digestive problems. Symptoms of coeliac disease - an autoimmune condition caused by a reaction to the gluten in wheat, rye and barley – can include stomach pain, diarrhoea and weight loss, but sometimes there may be no gut symptoms but problems such as anaemia, severe fatigue, mouth ulcers and even neurological problems. Misdiagnosis is common. “A quarter of people with coeliac disease have been treated for irritable bowel syndrome,” says McGough
Is coeliac different from intolerance?
Norma McGough Director of Policy, Research and Campaigns at Coeliac UK
The importance of early diagnosis In coeliac, inflammation of the gut lining leads to nutrient malabsorption. Over time this can lead to iron deficiency, anaemia, vitamin B12 deficiency and calcium malabsorption, increasing the risk of osteoporosis. “Early diagnosis and treatment with a gluten-free diet can reverse loss of bone mass within a year, but if diagnosis is delayed until after the menopause, the chances are much lower.”
Ask for a blood test A blood test can show antibodies produced in response to gluten, and indicate the likelihood of coeliac disease. This is not a definite diagnosis, but can be a fast way of ruling it out. “Those preparing for the test should remain on a glutencontaining diet for a period
“Boosting the health of your gut is one of the most effective ways to enhance your overall health and wellbeing. Find my top tips online at healthawareness.co.uk.”
“Coeliac disease is a lifelong, genetically-linked autoimmune condition while a food intolerance does not affect the immune system,” says McGough. Research is underway into the use of enzymes to manage coeliac disease by breaking down the gluten in the gut to reduce the damage. However, it can only complement the main treatment - a gluten-free diet – and not completely replace it. Gluten-free foods are available on the NHS in some areas and constitute a low-cost treatment for the NHS,. “It is postcode lottery,” says McGough. “The policy is currently under national review and results are due soon. The extra cost of buying gluten-free food for people with coeliac disease in retail is estimated at £10 a week. This is a disproportionate burden for those on low incomes, adding around 25 per cent to their typical food bills.” Meanwhile, Coeliac UK is looking at the results of its awareness campaigns in 201516 to see how best to increase awareness of the high levels of undiagnosed coeliac disease. McGough says: “If you have recurrent symptoms that might indicate coeliac disease ask your GP for a test.”
No one should die of bowel cancer or have to live with chronic bowel disease You can help us support young scientists like Hannah and the best UK science to save and change lives. Find out more at www.bowelcancerresearch.org or call 020 7882 8749
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