Gastroenterology Today Spring 2018

Volume 28 No. 1

Spring 2018

Gastroenterology Today In this issue Adjunctive therapy for the treatment of Helicobacter pylori infection

JAG

An unusual cause of abdominal pain

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The Difficult PEG: Low intercostal approach

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CONTENTS

CONTENTS 4

EDITORS COMMENT

6

FEATURE P robiotics: Adjunctive therapy for the treatment of Helicobacter pylori infection?

9

CASE REPORT An unusual cause of abdominal pain

11

CASE REPORT The Difficult PEG: Low intercostal approach

13

MEETING REPORT U EGW 2017

16

NEWS

26

BSG POSTERS

28

COMPANY NEWS

COVER STORY Inhealth expands local endoscopy services in London and Oxfordshire

Gastroenterology Today This issue edited by: Dr Andy Poullis c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHING DATES: February, June and October.

COPYRIGHT: Media Publishing Company Media House 48 High Street SWANLEY, Kent, BR8 8BQ PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company.

Next Issue Summer 2018

InHealth is the UK’s largest specialist provider of diagnostic and healthcare solutions.

Our flexible and dynamic approach is helping to meet some of health’s most pressing challenges – reducing waiting times, speeding up diagnoses, saving money and improving the overall patient experience.

With JAG accredited endoscopy units located in Essex, Suffolk, Peterborough and Cambridge, Oxfordshire, Gloucestershire, North West London, Bristol and Manchester, InHealth has led the development of “straight to test” community endoscopy and treated over 26,000 patients last year in the UK. We offer innovations such as trans nasal endoscopy with low levels of sedation and are the first independent provider to deliver services under the “2 week wait” pathway, providing robust onward referral pathways for patients with suspected cancer.

Our most recent Community Health Clinic opened in Romford in November 2017, providing a direct to test endoscopy pathway for GPs in Barking, Havering and Redbridge. Further investment in 2 additional endoscopy units in Oxford this summer will provide us with the opportunity to further support Oxfordshire CCG in their objectives to improve local access, bring care closer to home, improve cancer outcomes, reduce delays in diagnostic pathways and integrate care pathways between providers.

For more information please contact: Stuart Sedgwick-Taylor, Head of Endoscopy, InHealth Tel: 01494 560 000 or visit www.inhealthgroup.com/endoscopy

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On-going investment in state-of-the-art equipment and modern, spacious community clinics allows us to deliver high quality NHS endoscopy services with greater access to tests, shorter waiting times and improved clinical outcomes for patients.

Subscription Information – Spring 2018 Gastroenterology Today is a tri-annual publication currently sent free of charge to all senior qualified Gastroenterologists in the United Kingdom. It is also available by subscription to other interested individuals and institutions.

3

EDITORS COMMENT

EDITORS COMMENT Hidden gems

GASTROENTEROLOGY TODAY - SPRING 2018

4

“It is very difficult for medical students to get involved in areas traditionally thought of as “post graduate” but case reports are an ideal way to develop knowledge and skills based on interesting cases they have been exposed to.”

Although I don’t think Gastroenterology Today can compete with the New England Journal of Medicine and I wouldn’t want to compare our case reports to the case records of Massachusetts General Hospital but I do think the enclosed case reports demonstrate two clear factors.

We are surrounded by interesting cases, often amongst the large volume of day to day “routine” cases. These help to keep gastroenterology and medicine as fascinating subjects and I think for all of us help to maintain our on-going interest.

The second factor demonstrated in both of these reports is that the present generation of medical students are keen to get involved with many extra curricular professional development activities. It is very difficult for medical students to get involved in areas traditionally thought of as “post graduate” but case reports are an ideal way to develop knowledge and skills based on interesting cases they have been exposed to.

Both the St George’s case reports are 1st authored by students.

Gastroenterology Today is keen to support this type of publication. So next time you see an interesting case in clinic or on the wards think about utilising any keen medical students or junior doctors to look into it further and write a report!

Dr Andy Poullis St George’s Hospital, London

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Visit ukmedinet.com or call 0121 308 2333 to find out more.

FEATURE

PROBIOTICS: ADJUNCTIVE THERAPY FOR THE TREATMENT OF HELICOBACTER PYLORI INFECTION?

By Dr. Davinder Garcha, Medical Science Liaison, Protexin, Somerset, UK. www.protexin.com

Pathogenesis of Helicobacter pylori

Presence of H. pylori, in particular CagA-positive H. pylori, is associated with a range of gastric conditions, including peptic ulcers, chronic

Helicobacter pylori is known to infect the gastric mucosa and duodenum of over the half the world’s population, with those in developing countries most afflicted. Here in the UK, approximately

gastritis and stomach cancer. Typical treatment targets eradication of H. pylori, with the standard regimen for this involving a proton pump inhibitor (PPI) and double antibiotic therapy (triple therapy).

15% of the population harbours the bacterium. Infection with H. pylori is frequently asymptomatic, with initial acquisition usually having occurred by the time a person is 5 years old.1

The manner of H. pylori transmission is not fully elucidated, although

Safety and efficacy of triple therapy

the oral cavity is suspected as being a reservoir for both transmission

GASTROENTEROLOGY TODAY - SPRING 2018

6

and gastric reinfection, and evidence suggests that the faecal-oral route

In the UK, first line treatment for H. pylori eradication is a 7-day twice daily

may also be an important mode of transmission.2,3 It is highly adapted to

treatment triple therapy.5 Globally, first-line triple therapy is effective in

survive in the gastric environment, and undergoes four critical steps for

around 80% of cases, although rates are declining.6 These declines are

colonisation, infection and ultimately disease pathogenesis:

linked to increasing antibiotic resistance and poor patient compliance.

4

Adverse events are commonly seen in triple therapy, and may well be • Survival in gastric acid – bacterial urease creates ammonium which enables survival in the low pH environment of the stomach.

a contributory factor to poorer compliance and thus poorer efficacy.

Approximately 25-33% report adverse events during first-line therapy.7

• Flagella-mediated motility to epithelial cells – 4-7 flagella move H. pylori through the gastric mucosa epithelial layer to the less acidic basal layer.

• Attachment to cell surface receptors – bacterial adhesins interact with host cell receptors of the gastric lining, preventing displacement by peristalsis and gastric emptying.

• Toxin secretion – Pathogenicity of H. pylori is strongly correlated to

Antibiotics and the gut microbiota The benefit of antibiotics targeting pathogenic bacteria unfortunately comes with the negative effect of collateral damage to helpful commensals. The average adult gut is home to ~40 trillion bacteria.8 This ‘gut microbiota’, typically consisting of over 1000 bacterial species,

its production of Cytotoxin-associated gene A (CagA), with CagA-

is involved in the regulation of a range of host metabolic pathways.

positive infection in western countries seen in around 60% of infected

These include the metabolism of otherwise indigestible dietary fibre,

individuals.

and the maintenance of the enterohepatic circulation of bile acids.9,10

FEATURE Probiotic effect

Mechanism of action versus H. pylori

Secretion of lactic acid by lactic acid bacteria (LABs) such as Lactobacilli, Lactococcus and Streptococcus

Lowers pH of the stomach and inhibits urease activity17,18

Secretion of short chain fatty acids by LABs

Lowers pH and inhibits H. pylori growth19

Secretion of bacteriocins by Lactobacilli

Antimicrobial compounds with potential anti-H. pylori activity19

Secretion of antimicrobial substances and direct competition for binding sites

Prevention of H. pylori adhesion to epithelium by certain strains of Lactobacilli19

Mucin production stimulation

Restore mucus layer and inhibit adhesion20

Table 1. Mechanisms by which probiotics may mitigate H. pylori infection The gut microbiota, can however be disrupted by antibiotic treatment,

These studies demonstrate that probiotics are able to improve both

both in respect to overall number of cells and species diversity.

efficacy and safety, when used as adjunctive treatment alongside triple

Such alteration is associated with adverse events such as antibiotic-

therapy for H. pylori. This is thought to be due, in part, to the ability of

associated diarrhoea and Clostridium difficile associated diarrhoea.

probiotics to help maintain gut physiology by supporting the normal

Triple therapy for H. pylori infection is associated with adverse events

functioning of the microbiota.16 Furthermore, probiotics have a range

including diarrhoea, nausea, vomiting, abdominal pain and bloating.

of mechanisms by which they may mitigate the impact of H. pylori

11

infection, as described in Table 1.

Evidence of probiotics as an adjunct to triple therapy Probiotics are defined by the World Health Organisation as “live microorganisms which, when administered in adequate amounts, confer a health benefit on the host”. Probiotics have been shown to reduce the rate of antibiotic-associated diarrhoea and other adverse events caused by antibiotics.12,13 A randomised, double-blind, placebo-controlled trial was performed with a multi-strain probiotic consisting of seven bacterial strains (Protexin, UK), as an adjunct to triple therapy, in order to determine whether adjunctive therapy with probiotics could minimise the prevalence

Conclusion Triple therapy is associated with numerous side effects, which may contribute to poor patient compliance and lower eradication rates.

However, adjunctive treatment with probiotics, particularly multi-strain probiotic formulations, has been shown to both reduce gastrointestinal side effects and increase successful eradication. This may have the additional benefit of slowing the onslaught of antibiotic resistance.

To learn more about the use of probiotics in the treatment of H. pylori infection and other conditions, please visit http://www.bio-kult.com/ research or contact medical@protexin.com

of gastrointestinal side effects and improve the eradication rate.14 A total of 66 patients positive for H. pylori were randomised to receive either the multi-strain probiotic or placebo, alongside triple therapy.

The probiotic group had significantly higher H. pylori eradication rate than the placebo group (90.1% vs 69.7%; p=0.04), and also showed significant improvements for nausea/vomiting (6.1% vs 27.3%; p=0.02)

A network meta-analysis of 143 studies was performed to examine the comparative effectiveness of 14 different types of H. pylori treatment.15 This found that probiotic supplementation in addition to standard triple therapy was amongst the most efficacious treatments: risk ratio (95% CI) 1.24 (1.17-1.29) with 10/14 days probiotic supplementation. The adverse event profile was best in patients with probiotic supplementation: RR (95% CI) 0.65 (0.47-087) with 7 days probiotic supplementation.15

1. Rajindrajith S, Devanarayana NM, de Silva HJ. Helicobacter pylori infection in children. Saudi J Gastroenterol. 2009;15(2):86-94. doi:10.4103/1319-3767.48964.

2. Payão SLM, Rasmussen LT. Helicobacter pylori and its reservoirs: A correlation with the gastric infection. World J Gastrointest Pharmacol Ther. 2016;7(1):126. doi:10.4292/wjgpt.v7.i1.126.

3. Harris RB, Oren E, Bui D, Brown HE. Serologic Evidence for Fecal– Oral Transmission of Helicobacter pylori. Am J Trop Med Hyg. 2016;94(1):82-88. doi:10.4269/ajtmh.15-0297.

4. Kao C-Y, Sheu B-S, Wu J-J. Helicobacter pylori infection: An overview of bacterial virulence factors and pathogenesis. Biomed J. 2016;39(1):14-23. doi:10.1016/j.bj.2015.06.002.

In addition, a meta-analysis of 14 studies also found that eradication

5. National Institute for Health and Care Excellence. Helicobacter pylori

rates in the pooled probiotic-supplementation group was higher than in

testing and eradication in adults - NICE Pathways. https://pathways.nice.

control group, alongside standard triple therapy: OR (95% CI) 1.67(1.38-

org.uk/pathways/dyspepsia-and-gastro-oesophageal-reflux-disease/

2.02) (ITT analysis). Total adverse events were also lower in the probiotic

helicobacter-pylori-testing-and-eradication-in-adults#content=view-

group than in the control group: OR (95% CI) 0.49 (0.26-0.94).11

node%3Anodes-first-line-treatment. Accessed January 10, 2018.

GASTROENTEROLOGY TODAY - SPRING 2018

and diarrhoea (6.1% vs 24.2%; p=0.04).14

References

7

FEATURE 6. Urgesi R, Cianci R, Riccioni ME. Update on triple therapy for eradication of Helicobacter pylori: current status of the art. Clin Exp Gastroenterol. 2012;5:151-157. doi:10.2147/CEG.S25416.

7. Bohr URM, Malfertheiner P. Eradication of H. pylori Infection: the

and children. Cochrane Database Syst Rev. 2017;12:CD006095. doi:10.1002/14651858.CD006095.pub4.

14. Khodadad A, Farahmand F, Najafi M, Shoaran M. Probiotics for the treatment of pediatric Helicobacter pylori infection: a randomized

Challenge is on if Standard Therapy Fails. Therap Adv Gastroenterol.

double blind clinical trial. Iran J Pediatr. 2013;23(1):79-84. http://ijp.

2009;2(1):59-66. doi:10.1177/1756283X08100352.

tums.ac.ir/index.php/ijp/article/view/1426.

8. Sender R, Fuchs S, Milo R. Revised Estimates for the Number of

15. Li B-Z, Threapleton DE, Wang J-Y, et al. Comparative effectiveness

Human and Bacteria Cells in the Body. PLoS Biol. 2016;14(8):1-14.

and tolerance of treatments for Helicobacter pylori: systematic

doi:10.1371/journal.pbio.1002533.

review and network meta-analysis. BMJ. 2015;351:h4052.

9. Nicholson JK, Holmes E, Kinross J, et al. Host-Gut Microbiota Metabolic Interactions. Science (80- ). 2012;336(6086):1262-1267. doi:10.1126/science.1223813.

10. Jandhyala SM, Talukdar R, Subramanyam C, Vuyyuru H, Sasikala M, Nageshwar Reddy D. Role of the normal gut microbiota. World

doi:10.1136/bmj.h4052.

16. Vítor JMB, Vale FF. Alternative therapies for Helicobacter pylori: probiotics and phytomedicine. FEMS Immunol Med Microbiol.

2011;63(2):153-164. doi:10.1111/j.1574-695X.2011.00865.x.

17. Kim J-E, Kim M-S, Yoon Y-S, Chung M-J, Yum D-Y. Use of selected

J Gastroenterol. 2015;21(29):8787-8803. doi:10.3748/wjg.v21.

lactic acid bacteria in the eradication of Helicobacter pylori infection.

i29.8787.

J Microbiol. 2014;52(11):955-962. doi:10.1007/s12275-014-4355-y.

11. Zhu R, Chen K, Zheng Y-Y, et al. Meta-analysis of the efficacy

18. Gotteland M, Brunser O, Cruchet S. Systematic review: Are

of probiotics in Helicobacter pylori eradication therapy. World J

probiotics useful in controlling gastric colonization by Helicobacter

Gastroenterol. 2014;20(47):18013-18021. doi:10.3748/wjg.v20.

pylori? Aliment Pharmacol Ther. 2006;23(8):1077-1086. doi:10.1111/

i47.18013.

j.1365-2036.2006.02868.x.

12. Hempel S, Maher AR, Wang Z, et al. Probiotics for the Prevention and Treatment of Antibiotic-Associated Diarrhea A Systematic Review and Meta-analysis. Jama. 2012;307(18):1959-1969.

13. Goldenberg JZ, Yap C, Lytvyn L, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults ScheBo_GastroToday_Jan_2017 12/01/2017 17:18

19. Pacifico L, Osborn JF, Bonci E, Romaggioli S, Baldini R, Chiesa C. Probiotics for the treatment of Helicobacter pylori infection in children. World J Gastroenterol. 2014;20(3):673-683. doi:10.3748/ wjg.v20.i3.673.

20. Lesbros-Pantoflickova D, Corthésy-Theulaz I, Blum AL. Helicobacter pylori and probiotics. J Nutr. 2007;137(3 Suppl 2):812S-8S. http://www. ncbi.nlm.nih.gov/pubmed/17311980. Accessed January 5, 2018.

Addendum - IBS The article in the Autumn issue of Gastroenterology Today ‘In the age of Self-Management and ‘Doctor Google’, What Role for the Experts?’ was written by: Dr Simon Smale, Gastroenterologist and Medical Adviser to The IBS Network.

GASTROENTEROLOGY TODAY - SPRING 2018

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The IBS Network is the national charity that helps people with Irritable Bowel Syndrome (IBS) and has provided support to those with the condition and to healthcare professionals for over 25 years. For more information, visit www.theibsnetwork.org

Addendum - Protexin The article entitled – “The relationship between IBS and Bacteria” which appeared in our Autumn 2017 issue was written by Dr Ashton Harper, Head of Medical Affairs at Probiotics International Ltd (Protexin) manufacturers of popular probiotic ranges Bio-Kult and Lepicol. To read the article again please visit: www.gastroenterologytoday.com where the Autumn issue can be found.

CASE REPORT

AN UNUSUAL CAUSE OF ABDOMINAL PAIN PRESENTING TO THE GASTROENTEROLOGY OUTPATIENT DEPARTMENT Aayushi Shukla1, Dr Katherine Gordon2, Dr Robert Morgan2, Dr Arvind Kaul2, Mr Peter Holt2, Dr Andrew Poullis2 1 St George’s University London, 2 St. George’s Hospital, London A 47 year old gentleman presented with a history of left sided

TEST

abdominal pain, radiating into the flank. Eating exacerbated the pain, and he gained some relief taking non-steroidal antiinflammatory drugs. He described the pain as cramp-like, with some relief with stretching. He reported two previous similar episodes over the past 4months. He had a background history

RESULT

Anti-cardiolipin IgG

Negative

Immunoglobulin G/A/M

Normal

Complement C3/C4

Normal

Antinuclear antibody

Negative

ANCA

Negative

Lupus anticoagulant

Negative

Aldosterone

1140

Renin

13

Aldosterone/renin ratio

88

of appendicectomy and right sided renal artery dissection 4 years previously and subsequent hypertension, for which he was on amlodipine. He had a family history included ischaemic heart disease and hypercholesterolaemia. He was a non-smoker and drank 10units of alcohol a week.

On examination there were no peripheral stigmata of gastrointestinal disease. Pulse was 70 and regular, heart sounds were normal and the chest was clear. Abdominal examination revealed tenderness in the left flank but no organomegaly or masses.

Table 1. Vasculitic and connective tissue screen

A CT was performed (figure 1) that showed a left sided renal artery

He was diagnosed with a renal artery dissection, secondary to a

dissection associated with renal infarction, dissection of the right

likely underlying collagen vascular disorder with hypermobility.

iliac artery and the coeliac artery.

He was treated conservatively, with careful management of his blood pressure. He was discharged home with no further complications; with annual surveillance for aneurysm/dissection by the vascular team and review by the rheumatology team.

Discussion A

B

Renal artery dissection is a rare cause of abdominal pain. We with left sided abdominal pain with a background history of a right sided renal artery dissection resulting in hypertension. A

C

Figure 1. CT angiogram showing left renal artery dissection (A), right internal iliac dissection (B) and coeliac artery dissection.

renal artery dissection occurs due to a tear in the intima leading to the creation of a false lumen disrupting blood flow to the kidneys. The consequences of renal artery dissection include thrombus formation, renal infarction and hypertension. Renal artery dissections are associated with trauma (iatrogenic/blunt trauma),

Further investigations included an echo showing an ejection

or spontaneous with underlying connective tissue disorders such

fraction 65%, mild mitral regurgitation, trivial tricuspid regurgitation

as Ehler’s-Danlos syndrome and Marfan’s syndrome, fibromuscular

and trivial pulmonary regurgitation. A vasculitic screen and

dysplasia and malignant hypertension1. Our patient was diagnosed

investigation for connective tissue diseases were negative (results

with an underlying collagen vascular disorder with hypermobility.

in table 1). His Beighton score was 5/9 (measuring for joint laxity,

There have been less than 200 cases of spontaneous renal artery

where a score of 4 or greater equals major criteria for a benign joint

dissection reported in the literature since the first reported case in

hypermobility syndrome).

19442.

GASTROENTEROLOGY TODAY - SPRING 2018

presented the case of a 47-year-old gentleman who presented

9

CASE REPORT A literature review shows that patients with renal artery dissection

In conclusion, renal artery dissection is a rare event, and an

can present with non-specific symptoms such as flank pain,

unusual cause of abdominal pain presenting a diagnostic

hypertension, haematuria, pyrexia, headache, nausea and

challenge. Due to the non-specific presenting symptoms imaging is

vomiting . Differential diagnoses in such a patient include renal

key to diagnosis and management is heavily focused on controlling

colic, pyelonephritis, renal artery thromboembolism leading to renal

hypertension and preserving renal function.

3

infarction, renal vein thrombosis and renal abscess 4. Renal artery dissections usually present in otherwise healthy males in their 3040s with bilateral renal artery dissections occurring in 10-15% of

References

cases1,4.

1. Spontaneous Renal Artery Dissection (2007) Kanosky, J. & Lepor, H. Due to the condition being an unusual cause of abdominal pain combined with vague presenting symptoms, the diagnosis is often delayed until imaging is carried out. Imaging modalities include CT with contrast enhancement which identifies areas of renal infarction suggesting a vascular defect. CT angiography is the gold standard as it directly shows the extent of the dissection giving the most definitive diagnosis. Further investigations include testing for autoantibodies and connective tissue disorders to find an underlying cause. There are several management routes for patients with renal artery dissection: conservative management includes careful monitoring and follow up, hypertensive control and anticoagulation. Surgical options include vascular reconstruction,

Rev. Urol. 9(3): 156-160 2. Spontaneous renal artery dissection with renal infarction (2012) Renaud, S., Leray-Moragues, H., Chenine, L., Canaud, L., VemhetKovacsik, H. & Canaud, B. Clin Kidney J. 5(3):261-264.

3. Spontaneous renal artery dissection: three cases and clinical algorithms (2006) Stawicki, S., Rosenfeld, J., Weger. N., Fields, E. & Balshi, J. JHH 20: 710-718.

4. Spontaneous renal artery dissection complicated by renal infarction: A case report and review of the literature (2012) Katz-Summercom, A., Borg, C. & Harris, P. IJS 3(7):257-259.

nephrectomy or endovascular stenting to return normal renal blood flow and control hypertension1,5. Long term effects of renal artery

5. Nonoperative management of acute spontaneous renal artery

dissection include secondary hypertension due to renovascular

dissection (2002) Ramamoorthy, S., Vasquez, J., Taft, P., McGinn, R.

disease and renal infarction.

& Hye, R. Ann Vasc Surg 16(“):157-162.

GASTROENTEROLOGY TODAY - SPRING 2018

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Healthcare_Gastro_Today_Half_Advert_160118_100percent.indd 2

19/01/2018 14:52:39

CASE REPORT

THE DIFFICULT PEG: LOW INTERCOSTAL APPROACH Kotha S, Salehi S, Tao D, McNair A, Gulati M Queen Elizabeth Hospital, London, UK

Abstract Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive endoscopic procedure to provide nutrition when oral feeding is inadequate or unsafe. Identification of optimum position for placing the tube may be difficult and is largely achieved by trans-illumination and finger indentation prior to gastric puncture. However, this may not be possible in patients with an intra-thoracic stomach due to a hiatus hernia, skeletal deformity or previous gastric surgery. We report three patients where PEG placement by conventional methods was not feasible, but

Fig 1

Fig 2

feeding tubes were successfully placed using a low intercostal approach with a combination of radiological and endoscopic technique.

Case 2 Introduction PEG placement is minimally invasive endoscopic procedure with complication rate of 1-2.4% [1] and mortality rate of 0.8% [1-3].

Site selection for placement of PEG is paramount to safety and is achieved by appropriate trans-illumination through abdominal wall with visualisation of indentation of stomach by external palpation. This may be limited by previous surgery, large hiatus hernias, skeletal deformity and presents the most frequent obstacle in safely completing the procedure [4]. Attempts at placing PEG in such patients have higher risk of complications [2]. We report three patients who could not have conventional PEG or RIG (radiologically inserted gastrostomy) due

A 67-year-old gentleman presented with dysphagia due to chemotherapy and radiotherapy induced mucositis for recurrent oesophageal cancer. Distal oesophageal cancer was treated with oesophagectomy combined with chemotherapy and radiotherapy 3 years ago. He was unable to tolerate any oral intake and had lost 2 stones in weight over 1 month and it was felt he was unlikely to meet his nutritional requirements. Attempts at placing a nasogastric tube were unsuccessful due to severe pain and erythematous oropharynx.

PEG was unsuccessful as trans-illumination and finger indentation was not achieved. A RIG was attempted, but fluoroscopy revealed an intrathoracic stomach. He was discussed in gastrointestinal multidisciplinary meeting and it was felt that surgery would be risky in an

placement with a combined approach.

immunocompromised patient.

Case 1

Case 3

An 86-year-old gentleman presented with dysphasia and hemiplegia

A 91-year-old gentleman presented with facial paralysis due to CVA.

due to CVA (cerebrovascular accident). He had previously undergone

He had extensive co-morbidities including emphysema, diabetes mellitus

colectomy and partial gastrectomy for treatment of bowel cancer.

which made him dependent on carers. He had previously undergone partial

At week 4 following the CVA, he had persistent oropharyngeal

gastrectomy. Significant oro-pharyngeal dysphagia persisted eight weeks’

dysphagia confirmed on video fluoroscopy. Placement of PEG was

post CVA. During this period, nasogastric feeding resulted in aspiration

attempted endoscopically, but trans-illumination and finger indentation

pneumonia. PEG was attempted endoscopically, but trans-illumination and

could not identify a suitable position. A RIG was also attempted, but

finger indentation could not identify a suitable position. RIG was planned,

fluoroscopy showed small gastric remnant lying high above the costal

but CT abdomen prior to the procedure indicated no direct access to the

margin (Fig 1), so the procedure was abandoned.

stomach. The patient was discussed at the gastrointestinal multidisciplinary meeting for consideration of surgical approach. However, a laparotomy was

The case was reviewed at the gastrointestinal multidisciplinary meeting

deemed too risky due to co-morbidities.

for consideration of surgical approach. Due to patient’s complex medical background and poor functional baseline, laparotomy was

The consensus in all 3 cases was to proceed with a combined

deemed too risky.

endoscopic and radiological gastrostomy.

GASTROENTEROLOGY TODAY - SPRING 2018

to complex anatomy of stomach but had successful gastrostomy

11

CASE REPORT In our cases, due to previous surgeries with residual small gastric remnants, no clear point of access could be identified, by transillumination or finger indentation. In all three patients, RIG placement was advised but contrast studies prior to the procedure showed that the gastric remnants were high above the costal margin, rendering the procedure impossible. Each case was then carefully assessed by multidisciplinary team to identify the best option for long-term feeding and it was concluded that a combined radiological and endoscopic procedure would be the best option.

Fig 3

Fig 4

The potential complications of this procedure would essentially be same as conventional PEG placement with some exceptions. These include

Procedure

sedation related complications, aspiration, bleeding, perforation, local infection, aspiration and peri-stomal pain. Complications specific to intercostal approach would be pneumothorax, injury to lungs and bleeding.

A suitable position was identified for placement in lowest intercostal space anteriorly after air insufflation via endoscopy, and then using

There were no significant immediate complications in our patients. Case

ultrasonography and fluoroscopy to identify the stomach. Two

1 developed PEG site infection, which was successfully managed with

percutaneous T-fasteners were used to fix the stomach in position (Fig

antibiotics, and case 3 reported post-operative pain. Both are common

2), anchoring the stomach wall to anterior abdominal wall, and prevent

side-effects of conventional PEG insertion. As we gain more experience in

tube dislodgement and peritoneal leakage. Endoscopy aided guidewire

this method we can determine if these complications are encountered with

was placed via the gastric remnant into the jejunum with the aid of

higher frequency than conventional techniques of gastrostomy placement.

biopsy forceps (Fig 3&4). Position was confirmed fluoroscopically and a gastrojejunostomy tube was then passed into the jejunum and fixed in place. Feeding was commenced 24 hours after the tube was inserted.

Our cases demonstrate that, with combined radiological and endoscopic approach, intercostal approach to PEG insertion is safe in patients unable to have conventional PEG due to previous surgery or abnormal gastric anatomy. However, the cases should be chosen

Outcomes

carefully and discussed in a multidisciplinary setting to identify the best option for long term feeding.

Case 1: Patient developed localised PEG site infection, which was successfully treated with antibiotics. He was successfully discharged home.

References

Case2: Patient did not develop complications and was discharged

1. W.-K. Chang, S.-A. McClave, C.-Y. Yu, H.-H. Huang, Y.-C. Chao.

Positioning a safe gastric puncture point before percutaneous endoscopic gastrostomy. Int J Clin Pract. 2007;61(7):1121-1125.

home. He completed the chemotherapy/radiotherapy successfully and PEG was removed following this.

Case 3: Patient developed pain around PEG site in the immediate post procedure period. CT scan showed a small locule of air in the subhepatic space which was expected, but there was no evidence of fluid collections. The pain persisted, but there were no signs of infection or tube displacement. The patient’s respiratory status deteriorated due to GASTROENTEROLOGY TODAY - SPRING 2018

recurrent pneumonia and despite treatment with antibiotics he died 13 days after the PEG insertion.

Discussion These cases demonstrate a combined endoscopic and radiological approach is reasonable when abnormal anatomy of the stomach due to previous surgery or a large hiatus hernia precludes conventional PEG

3. Rimon E. The safety and feasibility of percutaneous endoscopic gastrostomy placement by a single physician. Endoscopy 2001; 33: 241–4.

4. Thornton FJ, Varghese JC, Haslam PJ et al. Percutaneous gastrostomy in patients who fail or are unsuitable for endoscopic gastrostomy. Cardiovasc Intervent Radiol 2000; 23: 279–84.

5. Wejda BU, Deppe H, Huchzermeyer H, Dormann AJ. Peg placement in patients with ascites: a new approach. Gastrointestinal endosc 2005, Jan; 61 (1): 178-80 Authors: Sreelakshmi Kotha, MBBS, MRCP; Shayon Salehi, MBChb, BSC, MRCP; Denise Tao, Medical student; Alistair McNair, MA MB Bchir FRCP PhD; Manpreet Singh Gulati, MBBS, DNB, MD, FRCR Affiliation: Department of Gastroenterology, Queen Elizabeth Hospital, London, United Kingdom

placement.

Correspondence: Dr Sreelakshmi Kotha, sreelakshmi_kotha@yahoo. com 00447949871727. Sreelakshmi Kotha is the article guarantor.

The literature describes cases where gastropexy with T-fasteners and

Disclosures: No conflicts of interest. No financial support or competing interests.

sutures has been used, but mainly in cases with ascites (5), or to reduce incidence of peri-stomal infections and leakage rather than cases like ours with abnormal anatomy.

12

2. McClave SA, Chang WK. Complications of enteral access.

Gastrointest Endosc 2003; 58: 739-51.

Author Contributions: All authors were involved in the clinical care and endoscopic management of the patient. All authors contributed to the writing. Informed consent was obtained from the patients for publication.

MEETING REPORT

UNITED EUROPEAN GASTROENTEROLOGY WEEK (UEGW) 2017 28 October – 1 November, Barcelona, Spain Progress in colorectal cancer screening, reducing the risk of gastrointestinal cancers and achieving long-term remission of Crohn’s disease with biosimilar infliximab CT-P13 were key developments reported at the 2017 United European Gastroenterology Week (UEGW) attended by 12,810 delegates from 116 countries.

Colorectal cancer screening should start at a younger age than currently recommended, according to a large French study1 that showed a major increase in detection of neoplasia in people aged 45-49 years compared to younger adults.

Most colonoscopy screening programmes for people at average risk for colorectal cancer currently enroll patients from the age of 50 years so there is limited information on the adenoma detection rate in younger patients. In addition, the incidence of colorectal cancer in people younger than 50 is increasing so there is growing interest in the potential benefit of screening at a younger age.

The new study prospectively analysed all 6027 colonoscopies (3308 women, 2719 men, median age 57 years) performed at one

Switching from originator infliximab to biosimilar CT-P13 maintains long-term efficacy in Crohn’s disease

endoscopy centre, Pôle Digestif Paris-Bercy in France, from 1 January to 31 December 2016. The aim was to explore detection rates for

Switching patients from originator infliximab (Remicade) to the biosimilar

neoplasia and adenoma in different age groups in a large population

CT-P13 (Inflectra) after 30 weeks maintained clinical response in patients

of consecutive patients undergoing colonoscopy as part of routine

being treated for active Crohn’s disease out to one year, showed late-

clinical practice. Patients undergoing interventional colonoscopy were excluded.

Results showed a two-fold increase in the mean number of polyps and adenoma detected from the age of 45 years, regardless of personal or familial history of polyps or cancer, while the risk in people younger than 30 was very low. The mean number of polyps doubled between the 4044 and 45-49 year age groups, from 0.196 to 0.389, as did the adenoma greater increase than that seen when comparing rates in the 45-49 age group with people aged 50-54 years.

Excluding people with a familial or personal history of polyps or cancer, the detection rate of neoplasia was significantly higher in patients from 45 to 49 years old (5.1%) compared to those younger than 45 (1.1%,

switching to CT-P13 compared to those continuing treatment with originator infliximab for the whole year and those treated with CT-P13 throughout.

The international phase III trial randomised 220 patients with active Crohn’s disease to one of four treatment regimens: CT-P13 for one year (56 patients); originator infliximab for one year (54); CT-P13 for 30 weeks before switching to originator infliximab (55); originator infliximab for 30 weeks, switching to CT-P13 (55). All patients had moderate to severe disease at baseline. Results reported previously for the primary outcome – a reduction in Crohn’s Disease Activity Index score of at least 70 points (CDAI-70) by six weeks – showed no significant difference

p<0.001).

between the treatment regimens and this continued to 30 weeks.

“These findings demonstrate a remarkable increase in the colorectal

Although the study was not powered to draw definitive conclusions

lesion frequency at the age of 45, with a particular increase in the

from the secondary endpoints, the new results indicated similar rates

detection rate of early neoplasia” said lead author David Karsenti, from

of CDAI-70 at 54 weeks in patients switched from infliximab to CT-

Clinique de Bercy, Pôle Digestif Paris Bercy, Charenton-le-Pont, France.

P13 (42%) as in those continuing with original infliximab for the entire

He concluded, “Regardless of the type of screening that is in place, the

year (38%), patients treated with CT-P13 throughout (44%) and those

results of our research strongly indicate that screening for colorectal

switching from CT-P13 to infliximab (39%). Clinical remission was also

cancer should begin at the age of 45.”

similar across the four treatment regimens at 54 weeks.

GASTROENTEROLOGY TODAY - SPRING 2018

detection rate, which increased from 12.1% to 22.5%. This was a much

breaking results from a randomised controlled trial2. In a secondary endpoint, efficacy, safety and immunogenicity were similar in patients

13

MEETING REPORT Reporting the data, Dr Alex Kudrin, a biopharmaceutical consultant from Brighton, UK, said, “In terms of safety, there were no new safety signals and the incidence was similar between groups in terms of adverse drug reactions, adverse events and serious adverse events.” The rate of infections was similar at 30 weeks and one year and immunogenicity was similar between patients who switched to CT-P13 or to originator infliximab.

Commenting on the findings, Dr Salomon Azoulay, chief medical officer with Pfizer Essential Health, which has co-developed CT-P13 (Inflectra) with Celltrion Healthcare, said, “At the end of 54 weeks, the data indicated there was no meaningful difference clinically, or from a safety or immunogenicity standpoint, between the treatment groups. This adds to the totality of evidence showing we can consider switching patients from Remicade to Inflectra and expect similar outcomes. This

Results showed that 0.24% (153 people) of the cohort given triple

also helps give confidence that we can treat patients with active Crohn’s

therapy developed gastric cancer over a median follow-up of 7.4 years

disease with Inflectra from the outset.”

(overall incidence 3.2 per 10 000 person years). The cumulative gastric cancer incidence rate in the H. pylori-eradicated cohort at 12 years was

Eradicating H. pylori reduces risk of gastric cancer by 22% in people over 60

0.1% in people younger than 40; 0.3% in the 40-59.9 year age group;

Eradicating Helicobacter pylori infection reduces the risk of developing

In people aged 60 and older the risk of gastric cancer was significantly

gastric cancer by 22% in people over 60 years of age, reported a large population-based study3.

Gastric cancer is currently the fourth leading cause of cancer death globally and affects mainly older people, with a median age of 69 years at the time of diagnosis. H. pylori infection is the most significant risk factor leading to the development of gastric cancer and is associated with more than three-quarters (78%) of cases throughout the world.

However, there has previously been limited evidence on the benefits of H. pylori eradication in older people over the age of 60.

GASTROENTEROLOGY TODAY - SPRING 2018

14

The new study retrospectively analysed data for all 73 237 patients given a course of clarithromycin-based triple therapy for H. pylori infection in Hong Kong between January 2003 and December 2012; 63 397 were successfully treated. Researchers looked at age-specific gastric cancer incidence over the same period using data from the Hong Kong Cancer and estimated the expected number of gastric cancer cases. They then determined the standardized incidence ratio for the cohort of patients receiving H. pylori eradication therapy and the general population of the same age group.

and 0.8% in people aged 60 and over. This compared to 0.1%, 0.3% and 1.1% in matched age groups for the general population.

lower in the group given H. pylori eradication therapy compared to the age-matched general population (standardized incidence ratio 0.78, 95% confidence interval 0.64-0.95, p=0.01). In contrast, no reduction in gastric cancer risk was seen in younger age groups.

“It has commonly been thought that it may be too late to give H. pylori eradication therapy to older people but we can now confidently recommend that H. pylori infection should be treated in the elderly to help reduce their risk of developing gastric cancer,” concluded Professor Leung.

Susan Mayor PhD, Medical Journalist, London, UK Declaration of interest Susan Mayor’s attendance at UEGW was supported by Pfizer.

1. Karsenti D. et al. Adenoma detection rate according to age: colonoscopy screening should start at 45 years old. UEGW 2017.

Abstract OP023 2. Kim Y-H et al. Phase III randomized controlled trial to compare

Reporting the study findings at the opening plenary session of UEGW,

biosimilar infliximab (CT-P13 with innovator infliximab in patients with

Professor Wai K. Leung, from the University of Hong Kong, said, “We saw

active Crohn’s disease: 1-year maintenance and switching results.

a significantly lower risk of gastric cancer in people over 60 who received antibiotic therapy for their H. pylori infection, in comparison to the general

UEGW 2017. Abstract LB04 3. Leung WK et al. Benefits of H. pylori eradication in preventing

population.” He continued, “The 22% reduction is remarkable, and

gastric cancer in the older population: results from a population-

suggests there is real value in the treatment of this infection.”

based study. UEGW 2017. Abstract OP004

Digestive Diseases Wales NEWS

Mercure, Holland House, Cardiff Thursday 1st - Friday 2nd March 2018

Wage, Bsg, Welsh surgical society and Welsh Chapters of aUgis and aCP are co-hosting the above meeting, which will be the largest Digestive Disease Federation type meeting held in Cardiff since Bsg was held there in 1986!

There will be a call for abstracts for free paper prize sessions as well as posters. There will be parallel sessions for nurses, a conference debate and a breakfast satellite symposium. The conference dinner and entertainment will be appropriate to St David’s Day! BSG will have its own away day on the Wednesday, and thus well-known experts and opinion leaders will be in the City for the whole three days.

CONFIRMED SPONSORS Aquilant - Ardmore Healthcare - Albyn Medical - Boston Scientific - Cantel - Cook - Janssen - Dr Falk Pharma - Mylan - Norgine

RegisteR online today! www.ukcreativeconferences.co.uk or call Creative Conferences on 0161 980 8180

DIGESTIVE DISEASES WALES MARCH 2018

GASTROENTEROLOGY TODAY - SPRING 2018

CONFIRMED SPEAKERS Julian Marchesi (Cardiff ) - David Sanders (Sheffield) - Chris Probert (Liverpool) - Siwan Thomas Gibson (London) Luigi Bonavina (Milan) - Abrie Botha (London) - Attila Nakeeb (Indianapolis) - Martin Lombard (Liverpool) Dhiraj Tripathi (Birmingham) - Mark Hudson (Newcastle) - George Webster (London) - Gideon Hirschfield (Birmingham) Mark Samaan (London) - Sunil Dolwani (Cardiff ) - Doug Speake (Edinburgh) - Rhiannon Harries (Cardiff ) Dale Vimalachandran (Chester) - Enrique Dominguez Muňoz (Santiago de Compostela) - Pär Myrelid (Linkoping) Nicola Fearnhead (Cambridge) - Barney Hawthorne (Cardiff )

15

NEWS • 1/3 of projects funded by the charity have

Crohn’s and Colitis UK releases first Research Impact Report after awarding £5.2 million to research in the last 10 years

subsequently attracted further funding.

• 50% of projects have involved patients in their project design or delivery.

• Almost 100 peer-reviewed scientific publications have featured our research.

• 10% of researchers have reported policy and practice changes as a direct result of

Patient information and support charity,

our research.

Crohn’s and Colitis UK1, has recently released a The Power of Research – 10 years of

Dr Wendy Edwards, Research Manager at

Crohn’s and Colitis UK research² which

Crohn’s and Colitis UK said;

details how the charity has awarded over £5.2million in research grants to over 80 groundbreaking research projects since 2008.

The report gives an overview of the projects the charity has funded, the researchers they have supported, and the impact³ this research has made in improving the lives of those affected by Inflammatory Bowel Disease4.

For over 30 years, Crohn’s and Colitis UK has

“This Research Impact Report is fantastic in showing the incredible work we have been

“This Research Impact Report is fantastic in showing the incredible work we have been investing in over the last 10 years. We have come a long way in our understanding of the complexities of Inflammatory Bowel Disease, but there is still so much we do not know and need to find out.”

investing in over the last 10 years. We have come a long way in our understanding of the

improving the lives of people with Inflammatory

complexities of Inflammatory Bowel Disease,

Bowel Disease. We are very proud of our

but there is still so much we do not know

collective achievements so far – but so much

and need to find out. These investments into

more needs to be done, with the fantastic

research are critical if we want to improve lives

donors, patients and researchers.”

today and have a world free from Crohn’s and Colitis tomorrow”

For more information about our research please visit www.crohnsandcolitis.org.uk/

been the leading charity funding research into

Dr Gill Holdsworth, Chair of the Research

Inflammatory Bowel Disease (IBD)5, funding

Strategy and Funding Committee at Crohn’s

life-changing research into the causes,

and Colitis UK said;

References

highlights the benefits that charity – funded

“Crohn’s and Colitis UK is committed to

1. Crohn’s and Colitis UK are fighting to

research brings:

continuing the journey of discovery and to

research

symptoms and treatments of IBD. The report achieve a better quality of life for the 300,000 people in the UK suffering physically and emotionally from these and other forms of Inflammatory Bowel Disease.

2. crohnsandcolitis.org.uk/10yearsofresearch 3. Impact accessed using Researchfish https://www.researchfish.net/ 4. 98% of the research funded has been GASTROENTEROLOGY TODAY - SPRING 2018

made possible by donations from members and supporters of Crohn’s and Colitis UK. 5. Crohns Disease and Ulcerative Colitis are the two main forms of Inflammatory Bowel Disease (IBD). These chronic conditions can cause ulceration and inflammation in the colon (Ulcerative Colitis) or any part of the digestive system (Crohn’s Disease).

Symptoms can include diarrhea (often with blood), severe pain, extreme fatigue, and dramatic weight loss. This means 1 in 210 people are living with these unpredictable, life-long and potentially life-threatening conditions.

16

The first 1 litre PEG bowel preparation1–3

NEWS

Cut the volume keep the efficacy PLENVU® offers: Superior successful overall bowel preparation compared to MOVIPREP® (PEG 3350 + sodium ascorbate + ascorbic acid + sodium sulfate + electrolytes) using PM/AM dosing (p=0.014)*1,4 Safety profile comparable to MOVIPREP®1,5–7 Flexible dosing schedules5 and is designed to maximise patient adherence *In the per protocol population. PM/AM: evening/morning.

Powder for Oral Solution PEG 3350, Sodium Ascorbate, Sodium Sulfate, Ascorbic Acid, Sodium Chloride, and Potassium Chloride PRESCRIBING INFORMATION: PLENVU® (Macrogol 3350 + Sodium ascorbate + Ascorbic acid + Sodium sulfate anhydrous + Electrolytes)

Fertility, pregnancy and lactation: There are no data on the effects of Plenvu on fertility in humans. There were no effects on fertility in studies in male and female rats. It is preferable to avoid the use of Plenvu during pregnancy. It is unknown whether Plenvu active ingredients/ metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breast-feeding or to abstain from Plenvu therapy. Undesirable effects: Diarrhoea is an expected outcome. Common: vomiting, nausea, dehydration. Uncommon: abdominal distension, anorectal discomfort, abdominal pain, drug hypersensitivity, headache, migraine, somnolence, thirst, fatigue, asthenia, chills, pains, aches, palpitation, sinus tachycardia, transient increase in blood pressure, hot flush, transient increase in liver enzymes, hypernatraemia, hypercalcaemia, hypophosphataemia, hypokalaemia, decreased bicarbonate, anion gap increased/ decreased, hyperosmolar state. Refer to the Summary of Product Characteristics (SmPC) for a full list and frequency of adverse events. Price and pack sizes: £12.43 (single treatment). Legal category: Pharmacy medicine For further information contact: Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, Middlesex, United Kingdom UB9 6NS. Telephone: +44(0)1895 826606. E-mail: medinfo@norgine.com Product licence number: PL 20142/0020 Date: November 2017 Company reference: UK/PLV/1117/0039

United Kingdom - Adverse events should be reported.

Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals Ltd on 01895 826606.

References: 1. Bisschops R, et al. Presented at UEGW 2016, poster number P0179. 2. Schreiber S, et al. Presented at UEGW 2016, poster number P1266. 3. DeMicco MP, et al. Gastrointest Endosc 2017; doi: 10.1016/j.gie.2017.07.047.

4. Norgine Ltd. DOF-PLENV-008 version 1.0. August 2017. 5. PLENVU® UK Summary of Product Characteristics. October 2017. 6. MOVIPREP® UK Summary of Product Characteristics. August 2017; 7. MOVIPREP® Orange UK Summary of Product Characteristics. August 2017.

GASTROENTEROLOGY TODAY - SPRING 2018

Presentation: Plenvu is administered in two doses. Dose one is made up of 1 sachet containing: macrogol 3350 100g, sodium sulfate anhydrous 9g, sodium chloride 2g, potassium chloride 1g. Dose 2 is made up of 2 sachets (A and B). Sachet A contains: macrogol 3350 40g, sodium chloride 3.2g, potassium chloride 1.2g. Sachet B contains: sodium ascorbate 48.11g, ascorbic acid 7.54g. Indication: For bowel cleansing in adults, prior to any procedure requiring a clean bowel. Dosage: Adults and elderly: A course of treatment consists of two separate non-identical 500ml doses of Plenvu. At least 500ml of additional clear fluid must be taken with each dose. Treatment can be taken according to a two-day or one-day dosing schedule. Two-day dosing schedule: First dose taken the evening before the procedure. Second dose in the early morning of the day of the procedure. Morning only dosing schedule: Both doses taken the morning of the procedure. The two doses should be separated by a minimum of 1 hour. Day before dosing schedule: Both doses taken the evening before the procedure. The two doses should be separated by a minimum of 1 hour. No solid food should be taken from the start of the course of treatment until after the clinical procedure. Consumption of all fluids should be stopped at least 2 hours prior to a procedure under general anaesthesia or 1 hour prior to a procedure without general anaesthesia.

Children: Not recommended for use in children below 18 years of age.

No special dosage adjustment is deemed necessary in patients with mild to moderate renal or hepatic impairment. Patients should be advised to allow adequate time after bowel movements have subsided to travel to the clinical unit. Contraindications: Hypersensitivity to the active substances or to any of the excipients, gastrointestinal obstruction or perforation, ileus, disorders of gastric emptying (gastroparesis, gastric retention), phenylketonuria, glucose-6-phosphate dehydrogenase deficiency,

toxic megacolon. Warnings and precautions: The fluid content of reconstituted Plenvu does not replace regular fluid intake. Adequate fluid intake must be maintained. As with other macrogol containing products, allergic reactions including rash, urticaria, pruritus, angioedema and anaphylaxis are a possibility. Caution should be used with administration to frail or debilitated patients, in patients with impaired gag reflex, with the possibility of regurgitation or aspiration, or with diminished levels of consciousness, severe renal impairment, cardiac failure (grade III or IV of NYHA), those at risk of arrhythmia, dehydration or severe acute inflammatory bowel disease. In debilitated fragile patients, patients with poor health, those with clinically significant renal impairment, arrhythmia and those at risk of electrolyte imbalance, the physician should consider performing a baseline and post-treatment electrolyte, renal function test and ECG as appropriate. Any suspected dehydration should be corrected for before use of Plenvu. There have been rare reports of serious arrhythmias including atrial fibrillation associated with the use of ionic osmotic laxatives for bowel preparation, predominantly in patients with underlying cardiac risk factors and electrolyte disturbance. If patients develop any symptoms indicating arrhythmia or shifts of fluid/electrolytes during or after treatment, plasma electrolytes should be measured, ECG monitored and any abnormality treated appropriately. If patients experience severe bloating, abdominal distension, or abdominal pain, administration should be slowed or temporarily discontinued until the symptoms subside. The sodium content, 458.5mmol (10.5g), should be taken into consideration for patients on a controlled sodium diet. The potassium content, 29.4mmol (1.1g), should be taken into consideration by patients with reduced kidney function or those on a controlled potassium diet. Interactions: Medicinal products taken orally within one hour of starting colonic lavage with Plenvu may be flushed from the gastrointestinal tract unabsorbed. The therapeutic effect of drugs with a narrow therapeutic index or short half-life may be particularly affected.

17

NEWS

GASTROENTEROLOGY TODAY - SPRING 2018

MOVIPREP® AND MOVIPREP® ORANGE PRESCRIBING INFORMATION REFER TO THE SUMMARY OF PRODUCT CHARACTERISTICS (SmPC) BEFORE PRESCRIBING Presentation: A box containing two transparent bags, each containing two separate sachets, A and B. Sachet A contains macrogol 3350 100g; sodium sulphate anhydrous 7.5g; sodium chloride 2.691g and potassium chloride 1.015g as white to yellow powder. Sachet B contains ascorbic acid 4.7g and sodium ascorbate 5.9g as white to light brown powder. Moviprep also contains aspartame (E951), acesulfame potassium (E950) and a lemon or orange flavour.

Uses: Bowel cleansing prior to any clinical procedure requiring a clean bowel. Dosage and administration: Adults and Older People: A course of treatment consists of two litres of Moviprep. A litre of Moviprep consists of one Sachet A and one Sachet B dissolved together in water to make one litre. This one litre reconstituted solution should be drunk over a period of one to two hours. This process should be repeated with a second litre of Moviprep to complete the course. A further litre of clear fluid is recommended during the course of treatment. This course of treatment can be taken either as divided or as single doses and timing is dependent on whether the clinical procedure is conducted with or without general anaesthesia as specified below: For procedures conducted under general anaesthesia: 1. Divided doses: one litre of Moviprep in the evening before and one litre of Moviprep in the early morning of the day of the clinical procedure. Ensure consumption of Moviprep as well as any other clear fluids has finished at least two hours before the start of the clinical procedure. 2. Single dose: two litres of Moviprep in the evening before the clinical procedure or two litres of Moviprep in the morning of the clinical procedure. Ensure consumption of Moviprep as well as any other clear fluids has finished at least two hours before the start of the clinical procedure. For procedures conducted without general anaesthesia: 1. Divided doses: one litre of Moviprep in the evening before and one litre of Moviprep in the early morning of the day of the clinical procedure.

Ensure consumption of Moviprep as well as any other clear fluids has finished at least one hour before the start of the clinical procedure. 2. Single dose: two litres of Moviprep in the evening before the clinical procedure or two litres of Moviprep in the morning of the clinical procedure.

Ensure consumption of Moviprep has finished at least two hours before the start of the clinical procedure. Ensure consumption of any clear fluids has finished at least one hour before the clinical procedure. Patients should be advised to allow for appropriate time to travel to the colonoscopy unit. No solid food should be taken from the start of the course of treatment until after the clinical procedure. Children: Not recommended in children below 18 years of age.

Contra-indications, warnings etc: Contra-indications: Known or suspected hypersensitivity to any of the ingredients, gastrointestinal obstruction or perforation, disorders of gastric emptying, ileus, phenylketonuria, glucose-6-phosphate dehydrogenase deficiency, toxic megacolon which complicates very severe inflammatory conditions of the intestinal tract. Do not use in unconscious patients. Warnings: Diarrhoea is an expected effect. Administer with caution to fragile patients in poor health or patients with serious clinical impairment such as impaired gag reflex, or with a tendency to aspiration or regurgitation, impaired consciousness, severe renal insufficiency, cardiac impairment (NYHA grade III or IV), those at risk of arrhythmia, dehydration, severe acute inflammatory bowel disease. Dehydration, if present, should be corrected before using Moviprep. The reconstituted Moviprep does not replace regular fluid intake and adequate fluid intake must be maintained. Semi-conscious patients or patients prone to aspiration should be closely monitored during administration, particularly if this is via a naso-gastric route. If symptoms indicating arrhythmia or shifts of fluid or electrolytes occur, plasma electrolytes should be measured, ECG performed and any abnormality treated appropriately. In debilitated fragile patients, patients with poor health, those with clinically significant renal impairment, arrhythmia and those at risk of electrolyte imbalance, the physician should consider performing baseline and post-treatment electrolyte, renal function test and ECG as appropriate. The possibility of serious arrhythmias, predominantly in those with underlying cardiac risk factors and electrolyte disturbance cannot be ruled out. If patients experience symptoms which make it difficult to continue the preparation, they may slow down or temporarily stop consuming the solution and should consult their doctor. Moviprep containing orange flavour is not recommended for patients with glucose and galactose malabsorption. Moviprep contains 56.2 mmol of absorbable sodium per litre (caution in patients on a controlled sodium diet), 14.2 mmol potassium per litre (caution in patients with reduced kidney function or patients on a controlled potassium diet). Interactions: Oral medication should not be taken within one hour of administration as it may be flushed from the GI tract and not absorbed. Pregnancy and lactation: There is no experience of use in pregnancy or lactation so it should only be used if judged essential by the physician. Side Effects: Very common or common: abdominal pain, nausea, abdominal distension, anal discomfort, malaise, pyrexia, vomiting, dyspepsia, hunger, thirst, sleep disorder, headache, dizziness, and rigors. Uncommon or unknown: Dysphagia, discomfort, abnormal liver function tests, allergic reactions including rash, urticaria, pruritus, erythema, angioedema and anaphylaxis, dyspnoea, electrolyte disturbances, dehydration, convulsions associated with severe hyponatraemia, transient increase in blood pressure, arrhythmia, palpitations, flatulence and retching. Refer to the Summary of Product Characteristics (SmPC) for full list and frequency of adverse events.

Overdose: In case of gross accidental overdosage, conservative measures are usually sufficient.

In the rare event of severe metabolic derangement, intravenous rehydration may be used.

Pharmaceutical Particulars: Sachets: Store in the original package below 25°C. Reconstituted solution: Keep covered. May be stored for up to 24 hours below 25°C or in a refrigerator. Legal Category: UK – Pharmacy only, Ireland - Prescription medicine. Packs: One pack of Moviprep or Moviprep Orange contains a single treatment. Basic NHS Price: UK £10.36, Ireland €13.26 Marketing Authorisation Number: UK: PL 20142/0005 (Moviprep), PL 20011/0006 (Moviprep Orange). IE: PA 1336/1/1(Moviprep), PA 1336/1/2 (Moviprep Orange). For further information contact: Norgine Pharmaceuticals Ltd, Moorhall Road, Harefield, Middlesex UB9 6NS Tel: +44 (0) 1895 826606 E-mail: medinfo@norgine.com Date of preparation/revision: November 2017. Ref UK/MPR/1117/0181

United Kingdom Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals Ltd on 01895 826606.

Ireland Ireland - Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

Norgine Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals on +44 1895 826606 or E-mail: medinfo@norgine.com PLENVU, MOVIPREP, NORGINE and the sail logo are registered trademarks of the Norgine group of companies.

UK/PLV/1017/0030e Date of preparation: November 2017.

UEG Week Vienna 2018 – putting science at forefront of gastroenterology United European Gastroenterology (UEG) Week is now one of the world’s largest gastroenterology and hepatology meetings.

Last year, at the 25th meeting in Barcelona, 13,000 delegates attended from 118 countries across the globe to discuss the most exciting developments in the digestive health field. Each year the meeting covers a wide range of digestive disease areas, cutting-edge post-graduate teaching sessions, endoscopic, ultrasound and surgical hands-on training and a range of ground-breaking gastrointestinal abstracts.

From October 20 – 24, 2018, UEG Week will take place in the city of Vienna. At the heart of Europe, Vienna is home to UEG through the House of European Gastroenterology. The congress is due to be held at Austria’s largest conference centre, The Austria Center Vienna, which hosted UEG Week in 2014 and 2016.

The UEG Scientific Committee carefully put together a world-class programme, featuring the latest advances in clinical management and the best new research in gastroenterology and hepatology.

The programme boasts a variety of different symposia and session types, ranging from Free Paper sessions to case-based discussions, ensuring a comprehensive offering for all attending delegates.

UEG Week will kick-off with the Postgraduate Teaching Programme (October 20 – 21), comprising of two days of excellent medical education and state-of-the-art sessions on digestive disorders from leading clinicians. The interactive session formats include tricky clinical cases, controversial debates and exciting video cases, supplying a perfect mix for gastroenterologists in training, as well as established gastrointestinal physicians and general practitioners.

The Postgraduate Teaching Programme follows a detailed threeyear curriculum (which can be started at any year of the cycle) and delegates receive a certificate once they have completed the programme.

Moving through to the main Scientific Programme (October 22 – 24), UEG Week will once again host the ‘Today’s Science; Tomorrow’s Medicine’ initiative, with this year’s theme on ‘Regenerative Medicine in Digestive Diseases’. Here, leading scientists present how the current stage of knowledge is ready to be used in clinical practice and discuss how strategies can be established to foster further progression in their area. The ‘Today’s Science; Tomorrow’s Medicine’ symposium series are a combination of invited sessions and Free Paper sessions, ensuring the world’s leading scientists and young researchers unite and help shape the future of gastroenterology and hepatology.

The extremely popular live endoscopy will be included in the core programme on October 23. Here, international experts and experienced chairs will demonstrate pioneering techniques via multiple parallel cases to ensure interactive learning without unnecessary gaps. This is supplemented with the Video Case Session, where short videos are submitted to the congress that

18 122817C_PLENVU 210mm X 297mm advert, 88mm X 247mm (PI)_Final.indd 2

08/12/2017 14:04

NEWS display new, unexpected or exceptional practice in diagnostic and therapeutic

Rome III Criteria

endoscopy.

To support the quality of submissions UEG offers a number of abstract related awards, including the Top Abstract Prize, where €10,000 is awarded to each of the top five abstracts submitted to the congress. As well as this, the UEG National Societies Committee and the UEG Scientific Committee jointly select 6-8 emerging clinical scientists as UEG ‘Rising Stars’ every year. Based on a track record of international quality research, this initiative provides the next generation of

NICE Guidelines (National Institute for Health and Care Excellence)

Recurrent abdominal pain/discomfort for >3 days/month in the past 3 months, associated with two or more of:

Abdominal pain/discomfort relieved by defaecation or associated with altered stool frequency/form, plus two or more of:

• Improvement with defaecation

• Altered stool passage

• Onset associated with change in stool frequency

• Abdominal bloating/distension

• Onset associated with change in stool form

• Symptoms made worse by eating • Passage of mucus

Table 1a

gastroenterologists with a durable platform

IBS is characterised by abdominal pain,

positively based on recognised clinical

to evolve their professional career. Other

bloating and change in bowel habit. With

criteria with some baseline investigations

notable awards at UEG Week include the

an overall prevalence of 10-20% several

such as blood tests to rule out anaemia,

Journal Best Paper Award (recognising the

diagnostic criteria for IBS have been

coeliac disease and a stool test for

best original scientific research published in

proposed based on history (with focus on

calprotectin to eliminate or point towards an

the UEG Journal), the UEG Research Prize

Red Flag (alarm) symptoms such as rectal

underlying inflammatory process. However,

(awarding €100,000 for excellence in basic

bleeding, weight loss and excluding family

corroboration studies for diagnostic criteria

science, translational or clinical research) and

history of colonic cancer), examination and

such as the Rome and Manning criteria for

the prestigious Lifetime Achievement Award

some baseline investigations to exclude

IBS are limited and somewhat inconsistent.

(honouring outstanding individuals who have

anaemia, or underlying inflammatory

In one validation study carried out across

made fundamental contributions to the world

conditions such as crohn’s, colitis and

1,848 adult patients who underwent a

of gastroenterology).

coeliac disease.

colonoscopy, the current diagnostic criteria fared reasonably in separating IBS from

Herbert Tilg, Chair of the UEG Scientific

organic conditions with sensitivity of 60%-

Committee, comments “Science is at the

Red Flag Indicators

95% and specificity of 70%-80%.

forefront of UEG Week and we are constantly trying to attract the best science and research to our meetings. The congress provides a fantastic opportunity for researchers around the world to submit and present their latest

• Age >50 years

Due to its high prevalence, IBS places a

• Short symptom history

large burden on the National Health Service

• Unintentional weight loss

(NHS). Increasing cost pressure faced by the NHS implies resource allocation needs

research findings. I, along with my fellow

• Nocturnal symptoms

committee members, are anticipating an

• Family history of bowel/ovarian cancer

and lack of yield of investigations, the tests

• Anaemia

need to be kept to a minimum. Moreover,

digestive health experts. We look forward to

• Rectal bleeding

flexible sigmoidoscopy and colonoscopy

welcoming new and returning delegates at

• Abdominal mass

exciting week of scientific advances and updates from some of the world’s leading

UEG Week Vienna 2018.”

Table 1b

constitute the most expensive element of any diagnostic workup for IBS and according to one study constitute about 50%-75% of the total management cost

However, diagnosing IBS can sometimes

of IBS. Other data suggest that although

submission and practical information, visit:

be challenging and uncertain for several

over a million consultations are carried

www.ueg.eu/week

reasons. These include the absence of

out every year in gastroenterology and

a consistent biological marker, many

surgical outpatients in England, with several

symptoms being difficult to quantify,

hundreds of millions spent on colonoscopy,

sometimes with considerable heterogeneity

clinicians are failing to positively diagnose

and variation between individuals. Multiple

IBS. This study suggests less than 2,000

overlapping organic conditions can also

patients per year are diagnosed with the

By Ravi Karwa, Associate Specialist

make clinicians risk averse with a tendency

condition in England. Furthermore, half

& Anurag Agrawal, Consultant

to investigate using invasive investigations,

the patients who undergo colonoscopy

Gastroenterologist at the Department

such as colonoscopy or sigmoidoscopy.

are subsequently discharged without any

2018, including delegate registration, abstract

Irritable Bowel Syndrome (IBS) and Endoscopy

follow up again implying that many of these

of Gastroenterology, Doncaster Royal Infirmary and Medical Adviser to The IBS

If the current guidance is to be followed,

patients did not need a colonoscopy in the

Network charity.

IBS can be diagnosed relatively easily and

first instance.

GASTROENTEROLOGY TODAY - SPRING 2018

To find out more about UEG Week Vienna

to be judicious. Due to the high prevalence

19

NEWS

sharing the future of digestive health

Vienna, Austria October 20–24, 2018 Venue: Austria Center Vienna

GASTROENTEROLOGY TODAY - SPRING 2018

20

Europe’s Leading Gastroenterology Meeting Young GI Network Postgraduate Teaching Programme Awards and Grants Live Endoscopy Guidelines in Clinical Practice Abstracts on Fire: Frontiers in Research Advances in Clinical GI & Hepatology Endoscopic Hands-on Training Translational/Basic Science Clinical Case Sessions Poster Sessions Surgical Learning Area Technical Exhibition World-Renowned Experts Therapy Updates Controversial Debates Ultrasound Learning Area

Find out more, visit www.ueg.eu/week

Registration includes free UEG Week 24/7 access Abstract Submission Deadline: April 20, 2018

NEWS The Yield of Colonoscopy in Patients With Non-Constipated Irritable Bowel Syndrome: Results From a Prospective, Controlled US Trial Lesion

IBS patients (n=466), n (%)

Controls (n=451), n (%)

P value

Polyps

68 (14.6)

155 (34.4)

Adenoma

36 (7.7)

118 (26.1)

Mass

0 (0)

1 (0.2)

NS

Mucosal erythema or ulceration

23 (4.9)

8 (1.8)

<0.01

Diverticulosis

41 (8.8)

96 (21.3)

<0.0001

Angiodysplasia

1 (0.2)

2 (0.4)

NS

Hemorrhoids

85 (18.2)

74 (16.4)

NS

Anal fistula

0

1 (0.2)

NS

<0.0001

Table 2 Colonoscopic findings in IBS patients and controls

1 IBS, irritable bowel syndrome; NS, not significant.

There are three principal reasons why

In addition, there is data to suggest that

III criteria for the diagnosis of irritable

a colonoscopy can be carried out in

compared with other health professionals,

bowel syndrome in secondary care.

this group of patients. Firstly, to identify

IBS experts are more confident in diagnosing

Gastroenterology. 2013;145(6):1262-70.

organic diagnoses which may explain the

the condition on the basis of history and

symptoms. However, trial data suggests

examination alone, thereby reducing the

the prevalence of organic conditions such

need for invasive endoscopy procedures.

bowel syndrome in an increasingly cost-

In summary, although the current diagnostic

Gastro 2015 Oct; 6(4): 246–251.

as Inflammatory Bowel Disease (IBD) or microscopic colitis is approximately 2% in patients below the age of 50 with a pre-test clinical diagnosis of Irritable Bowel Syndrome. The second reason is to diagnose incidental findings such as colorectal cancer in the younger age group, but, there is no evidence that the incidence of such lesions is higher in patients with nonspecific IBS-type symptoms than in asymptomatic patients

criteria for IBS is not always applied in clinical practice, there is some evidence of their utility discriminating IBS with other organic conditions. In the appropriate patient with IBS symptoms and associated alarm symptoms, there is a clear defined role for

6. Ang YS, Macaleenan N, Mahmud N, et

symptoms. Eur J Gastroenterol Hepatol

A lack of awareness of IBS criteria and the

2002;14:1073-7.

procedures with no health benefit to the

relatively low yield, comparable with those

patient and a considerable expense to the

in asymptomatic individuals below the age

taxpayer.

7. Spiegel BMR, Gralnek IM, Bolus R, et al.

Is a negative colonoscopy associated with reassurance or improved health-related quality of life in irritable bowel syndrome?

Gastrointest Endosc 2005;62.

of 50. [Table 2] The third reason is that a References

8. Anderson V, et al. A survey evaluating

reassurance to patients with IBS. However, 1. www.nice.org.uk/guidance/cg61 2. Theromefoundation.org/assets/pdf/19_ RomeIII_apA)885-889.pdf 3. Ford AC et al. Validation of the Rome

general practitioners, gastroenterologists and experts diagnostic approaches to Inflammatory Bowel Disease, Irritable Bowel Syndrome and Chronic Constipation in five European Countries.

Gut 2014;63(Suppl 1):A1–A288.

IBS-C

IBS-D

Type of Physician

Expert/GE/GP

Expert/GE/GP

Correct diagnosis

88/56/31

92/72/64

Incorrect diagnosis

4/4/5

8/12/14

Don’t know

8/40/64

0/16/22

GASTROENTEROLOGY TODAY - SPRING 2018

younger patients with IBS diagnosis.

Am J Gastroenterol 2002;97:2812-9.

risk patients with non-specific colonic

to many patients undergoing endoscopy

higher health related quality of life scores in

syndrome patients: a systematic review.

be undertaken with greater discrimination.

specific gastrointestinal indications has

associated with increased reassurance or

utility of diagnostic tests in irritable bowel

al. The yield of colonoscopy in average-

shown that colonoscopy done for non-

whether recent or distant, was not

5. Cash BD, Schoenfeld P, Chey WD. The

such symptoms, such procedures need to

practice of defensive medicine is leading

researchers have found that colonoscopy,

aware National Health Service. Frontline

endoscopy. However, in the absence of

of similar age. Previous studies have

negative colonoscopy may provide some

4. Soubieres A, et al. Burden of irritable

Table 3

21

NEWS Dr Anthony Hobson, Consultant Clinical Scientist and Director at the Functional Gut

The IBS Network charity to hold 2nd UK conference ‘Exploring the selfmanagement of IBS’

Clinic commented: “The IBS Network provides an invaluable service for patients as the ‘go to’ place for information about IBS and its causes and advises how people can take control of their

Saturday 14 April 2018, Sheffield Hallam

condition. We really wanted to be part of this

University, South Yorkshire

event which helps to increase education and awareness about IBS using the latest scientific data derived from credible sources.”

The IBS Network, the national charity which supports thousands of people living with

On the day, chaired by Yvonne McKenzie,

Irritable Bowel Syndrome (IBS), is proud

Clinical Lead in IBS for the Gastroenterology

to be hosting its second IBS conference

Specialist Group of the British Dietetic

and exhibition on 14 April 2018 in Sheffield.

Association, several leading specialists

Following the inaugural event’s success in

including Dr Simon Smale, Dr Peter Whorwell,

2016, this year’s conference will explore the self-management of IBS and what that really means both from a sufferer’s and healthcare professional’s perspective.

Dr Adam Farmer and Dr Anthony Hobson will present on different aspects of IBS, as well as providing insights from people living with the condition. After each talk, there will be the opportunity for audience engagement with

Headline sponsor of the 2018 conference

time for open debate and Q&As. A number

is the Functional Gut Clinic, the UK’s first

of breakout sessions are also planned for

dedicated, independent and UKAS accredited

smaller group discussions with delegates to

gastrointestinal physiology service with clinics

understand what works for them and what they

in London, Manchester and other UK regions.

want for the future.

faecal-immunochemical-test.co.uk

GASTROENTEROLOGY TODAY - SPRING 2018

22

“The IBS Network provides an invaluable service for patients as the ‘go to’ place for information about IBS and its causes and advises how people can take control of their condition. We really wanted to be part of this event which helps to increase education and awareness about IBS using the latest scientific data derived from credible sources.”

A new resource for bowel cancer diagnosis

Patient presents at GP with abdominal symptons

A FIT Assay for Suspected Colorectal Cancer (CRC)

Patients triaged based on risk factors

www.faecal-immunochemical-test.co.uk is a new website dedicated to raising awareness amongst Clinicians and Laboratories about the value of testing for faecal occult blood using the immunochemical method (FIT).

SUSPECTED COLORECTAL CANCER

FIT is being adopted by the bowel cancer screening programmes and is also now recommended by NICE DG30 to guide referral for colorectal cancer in primary care.

FAECAL IMMUNOCHEMICAL TEST for Hb

Find out all about FIT at www.faecal-immunochemical-test.co.uk

Gastro-Today_FIT Web Feb 2018.indd 1

■

FIT for Clinicians

■

FIT for Patients

■

FIT for Laboratories

■

Case Studies and Reports

■

Literature and Publications

■

Videos

■

Products and Logistics Solutions

NEGATIVE

POSITIVE Refer for urgent colonoscopy

23/01/2018 12:22:19

NEWS Alison Reid, CEO at The IBS Network, said: “Following the huge success of our first IBS conference in 2016, we are proud to be hosting the second event here in Sheffield where the charity began and has been based for over 26 years. We look forward to welcoming all our members and healthcare specialists from across the UK for an opportunity to talk openly about IBS, to overcome the embarrassment surrounding the condition and discuss how we can better support people in the future.”

The IBS Network charity would like to thank all of its sponsors and exhibitors for supporting the conference. Full details can be found at https://www.theibsnetwork.org. To find out more about sponsorship opportunities, please email alison@theibsnetwork.org If you would like to attend, tickets are now available to buy from £5 via the charity’s website or call 0114 272 3253.

Digestive Diseases Wales Conference, Cardiff 1&2 March 2018

The Welsh Association for Gastroenterology and Endoscopy (WAGE) prides itself in the strong links between medical and surgical gastroenterologists in the Principality. WAGE also has members from the GI radiology,

The Boston Scientific State-of-the-Art speaker will be Prof Attila Nakeeb (Indianapolis) on management of common bile duct stones (including developments in ERCP and direct cholangioscopy). The Mylan State-of-the-Art speaker will be Prof Enrique Dominguez-Muñoz (Santiago de Compostela) on What’s New in Pancreatology?. Other confirmed speakers include Dr Siwan Thomas-Gibson (JAG Lead), Prof David Sanders (Sheffield), Prof Martin Lombard (BSG President), Dr Dhiraj Tripathi and Prof Gideon Hirschfield (Birmingham), Dr George Webster (UCLH), Dr Mark Hudson (Newcastle), Prof Attila Nakeeb (Indianapolis), Dr Luigi Bonavina (Milan), Ms Nicola Fearnhead

(Cambridge) and Dr Par Myrelid (Linkoping, Sweden).

There will be a pre-dinner debate on whether we should all be taking low-dose aspirin for GI and liver cancer prevention, and a breakfast symposium on inflammatory bowel disease, courtesy of Janssen. The entertainment on the Thursday evening will include some surprises that reflect St David’s Day. There will be a parallel “Associates” session on the Friday 2 March for the benefit of nurses, clinical nurse specialists and allied health professionals.

There will be three streams of abstract submission, each with a prize (6 Free Papers, Posters, and a parallel Welsh Surgical Society Ivor Lewis Medal prize session).

For more details please follow www.wage.org. uk and for abstract submission visit www.welshsurgeons.com.

The meeting is being facilitated by Creative Conferences (www.ukcreativeconferences. co.uk) and registration is via this site.

Miles Allison: Chair ddW Programme Committee Consultant Gastroenterologist Royal Gwent Hospital Newport NP20 2UB Miles.allison@wales.nhs.uk

GASTROENTEROLOGY TODAY - SPRING 2018

Those of us working in the devolved administrations of Wales, Scotland and Northern Ireland regularly remind the British Society of Gastroenterology (BSG) that the Society represents the GI and liver communities working within four very different health services.

The Four-Nations Committee is the established forum for reviewing how these differences affect the delivery of healthcare to patients with gastrointestinal and liver disease. This Committee is a subset of BSG Clinical Services but meets only once per year. To strengthen the sustainability of “Four Nations” collaboration, the annual BSG Council and Strategy Awayday rotates between the nations, and is followed by joint meetings of the BSG and the local gastroenterology societies. Edinburgh hosted such a meeting in 2016, and the Ulster and Irish Societies of Gastroenterology co-hosted the BIG (British and Irish Gastroenterology) meeting in Belfast in April 2017. This year the baton passes to Wales, and we look forward to welcoming many of you to The Mercure, Cardiff for an impressive two-day extravaganza starting on St David’s Day, Thursday 1 March 2018.

histopathology, nursing and allied healthcare professional communities. The current WAGE President, Prof Jared Torkington, secured agreement that the normal surgical Spring meetings in Wales will merge with us in the creation of “Digestive Diseases Wales (ddW)”!

There are five “stakeholder” organisations: WAGE, BSG, Welsh Surgical Society and the Welsh Chapters of the Association of Upper GI Surgeons (AUGIS) and the Association of Coloproctology of Great Britain and Ireland (ACPGBI). This has led to the programme having a long gestation period, but we have gathered a hugely impressive national and international cast for what promises to be the biggest GI/liver meeting in Wales since BSG came to Cardiff in 1986.

23

NEWS Study Presented at ASCO GI 2018 Shows Circulating Tumor Cell Blood Test Detects Early Stage Colorectal Cancer And PreCancer With High Accuracy

CTCs are cancer cells that detach from

tests in more than 80 percent of patients

a primary tumor and circulate through

who did not undergo invasive colonoscopy

the bloodstream and are a fundamental

screening. This test can be an option for

mechanism of metastasis. CTCs have

these individuals and boost compliance.”

New test could potentially be offered at less than $150 enabling high compliance and global adoption SUNNYVALE, Calif. — January 17, 2018 — CellMax Life, a leading cancer diagnostics company enabling early cancer detection and management with globally affordable non-invasive blood tests, today announced results from a new study showing that its circulating tumor cell (CTC) blood test, based on its proprietary CMxTM platform, can detect colorectal cancer at an early stage – and in many cases, pre-cancerous lesions – with accuracy ranging from 84 to

long been known to be valuable in cancer detection, but most technologies using

The authors are planning more studies in

CTCs are only able to detect late-stage

Taiwan and will be extending the studies

cancer. The CellMax CTC blood test “liquid

to the United States. The fundamental

biopsy” detects these CTCs in the blood at

mechanism of circulating tumor cell

the earliest stages. This is one of the first

shedding, and the capture using the CMx

clinical studies to show that CTCs can be

platform, are the same across all solid

useful for detecting early, more treatable

tumors. Thus, this platform is expected to

stages of cancer.

provide favorable results for other solid

The researchers enrolled 620 people over the age of 20 who were either visiting the hospital for routine colonoscopies or had confirmed colorectal cancer. After a colonoscopy and biopsy, 438 people were found to have either adenomatous polyps (pre-cancerous growths) or early to latestage colorectal cancer. The remaining study participants had no signs of precancerous growths or colorectal cancer and

88 percent.

were the comparison group.

Colorectal cancer is among the most

Two milliliters (about half a teaspoon) of

preventable cancers when detected early.

peripheral whole blood were tested from

Yet, it is the second leading cancer killer

each subject for CTC analysis through a

in the United States. Traditional methods

routine blood draw. The blood samples

like colonoscopies and stool-based tests

were then processed through the CMx

are invasive or inconvenient. For these

platform. The results of these assays were

reasons, compliance with colorectal cancer

then compared in a blinded analysis with

screening remains low, leading to most

the colonoscopy results.

colorectal cancers being detected in late stages, when survival rates are poor.

The study results showed that the test’s sensitivity ranged from 77 percent for

GASTROENTEROLOGY TODAY - SPRING 2018

24

tumors such as breast, lung and prostate cancers.

The data from the study, sponsored by Taiwan’s Ministry of Health and its largest hospital, the Chang Gung Memorial Hospital, will be presented by lead author, Dr. Wen-Sy Tsai (MD, Ph.D.) at the 2018 ASCO Gastrointestinal Cancers Symposium on Saturday, January 20. Attendees can also visit CellMax Life at booth #27 at the conference to learn more about the CellMax CTC blood test for colorectal cancer and the study’s results.

About CellMax Life CellMax Life is a leading cancer diagnostics company whose mission is to transform how cancer is diagnosed and managed with globally affordable non-invasive tests for early cancer detection and management.

CellMax Life’s unique expertise in circulating tumor cells (CTC) and next

“The positive results of this study prove that

detection of CTCs in pre-cancerous lesions

the CellMax CTC blood test can address

to 87 percent for stage I-IV cancers. The

the unmet need for a convenient and

accuracy of the results, taking into account

accurate test for early colorectal cancer

both sensitivity and specificity, was high

detection; since the test only requires

and ranged from 84 to 88 percent for

a routine blood draw, it can be easily

pre-cancerous and cancerous samples.

integrated into a patient’s regular physical

Additionally, the accuracy of this test was

exam, increasing compliance,” said study

superior to that of fecal occult blood testing

CellMax Life’s tests include CellMax-DNA

co-author Ashish Nimgaonkar, MD, a

(FOBT), a guideline-recommended stool

Hereditary Cancer Risk Test, CellMax-

gastroenterologist and medical director at

test for colorectal cancer screening.

CRC Colorectal Cancer Screening Test,

generation sequencing (NGS) of DNA, as well as circulating tumor DNA (ctDNA) has enabled it to offer highly effective precision medicine solutions for healthy people, as well as patients diagnosed with cancer.

CellMax-Prostate Cancer Test, CellMax-

the Center for Bioengineering Innovation & Design at Johns Hopkins University.

“Early detection is perhaps the only real

LBx Liquid Biopsy for immunotherapy and

“Additionally, research conducted by the

cure for cancer. To be effective, tests for

targeted therapy selection and CellMax-

American Cancer Society and Centers for

early cancer detection need to be non-

PanCa Monitoring Test. All clinical testing

Disease Control and Prevention states that

invasive, easy, highly affordable and

is performed at CLIA and CAP accredited

test affordability is the number one reason

accurate, and our CTC blood test meets all

laboratories in Sunnyvale, California and

patients cite for not undergoing regular

of these requirements,” said Atul Sharan,

Taipei, Taiwan.

screening for colorectal cancer. This blood

co-founder and CEO of CellMax Life.

test could potentially be offered between

“Recent surveys reveal a preference for

For additional information, please visit

$100 and $150.”

blood tests over stool-based screening

www.cellmaxlife.com

NEWS Supporting stem cell therapy: the money, the management and the message Author: Fiona Veira-McTiernan, Head of Research at Core The Core Derek Butler Fellowship is a 3 year grant awarded by Core for research into disorders of the upper gastrointestinal tract.

The award is currently held by Dr Conor McCann, at the Stem Cells and Regenerative Medicine section of the UCL Great Ormond Street Institute of Child Health (ICH).

Core is excited to fund research that could realistically support the development of new therapies for gut disorders in the not too distant future. We are also keen to work responsibly within the framework drawn up in the recent Lancet Commission on ‘Stem cells and regenerative medicine’ (Lancet. 2017 Oct 3). Regenerative medicine elicits high hopes but has arguably not managed to deliver many reliable successes yet. This gap between expectation and reality damages the social contract that allows the field to operate.

To address this issue and to ensure regenerative medicine can deliver clinical and public benefits the Lancet’s report asks for better science, better funding models, better governance and better public and patient engagement. In this short article we aim to introduce Dr McCann’s work and explore the

within the tissues. Once this is accomplished

manage expectations and maintain trust with

he will test whether the ENSC are able to

patients and the public.

restore nNOS+ nerve cells function in the transplanted tissues and whether this leads

Core funds both basic and clinical research,

to a recovery of gut function (peristalsis,

putting processes in place to ensure only

sphincter relaxation and gastric emptying).

the best science is funded. UCL/ICH deliver

Dr McCann will also examine how the

world-leading research by encouraging close

microenvironment responds to the integration

collaboration between scientists and clinicians

of the ENSC by looking at the gene expression

and by investing in new first-class research

profile of the tissues. This will be particularly

facilities. All animal studies and research

interesting in the diabetic gastroparesis

publications are performed to NC3Rs ARRIVE

model as it will show whether ENSC are

guidelines, to optimise the dissemination of

able to rescue function in an unfavourable

information. Additionally, both Great Ormond

pathological microenvironment.

Street Institute of Child Health and Core actively support the development of Clinical

If he is successful Dr McCann’s findings will

Academics – a key strategic priority for Core.

progress onto large animal work and could lead to first in human trials within 5-6 years, which

Crucially, both organisations actively support

could inform the development of new therapies

the need to engage patients and the

for achalasia, diabetic gastroparesis and other

public through appropriate communication

gastrointestinal conditions in the future.

channels (including social media) and have a meaningful discussion about the realistic

Core is enthusiastic about the potential of

aims, outputs and potential impact of stem

this research to deliver patient benefit and

cell therapy and regenerative medicine. UCL/

equally keen that it aligns with the Lancet’s

ICH involve patients and their families in the

report recommendations. Funding excellent

development of studies and keep them up to

basic research and ensuring it is carried out

date on the outcome of the research. Core

(and reported) rigorously; investing to develop

aims to engage their supporters with their

clinical scientists and create academic good

funded research through Facebook, Twitter

manufacturing facilities; and taking responsibility

and e-newsletters, as well as directly at patient

for engaging the public in a dialogue about

events and conferences. To inform, engage

stem cell research, are three of the Lancet’s

and support people affected by digestive

recommendations that stand out for Core. Their

disorders is an essential component of Core’s

aims are to: ensure the provision of good quality

work and as an organisation we welcome the

preclinical evidence that can inform clinical trials,

emphasis on responsible patient and public

facilitate the transition between basic and clinical

engagement that the Lancet report asks for,

research and, importantly, foster understanding,

and that UCL/ICH delivers.

implications for funders such as Core of some of the specific recommendations made in the Lancet’s report.

Dr McCann is exploring the use of enteric disorders: oesophageal achalasia (impaired peristalsis and sphincter relaxation of the oesophagus) and diabetic gastroparesis (delayed stomach emptying). Both disorders are characterised by dysmotility caused by loss of a particular type of nerve cell known as Nitrous Oxide Synthase neurons (nNOS+). The loss of these nerve cells causes significant problems with the movement of food along the gut.

For his Fellowship work Dr McCann is using mouse models of the disorders. Dr McCann is delivering ENSC into the lower oesophageal sphincter and into the stomach of the mice

GASTROENTEROLOGY TODAY - SPRING 2018

neural stem cells (ENSC) to treat two upper GI

and examining whether the stem cells integrate

25

POSTERS Title The Analysis Of Bile Salt Resistance Of Bacteria Isolated From The Human Biliary Tract Background The gastrointestinal tract is home to 10 trillion bacteria 1 and dysbiosis within this microbiota has been linked with autoimmune diseases such as Inflammatory Bowel Disease, Rheumatoid Arthritis, type I Diabetes Mellitus and Hasimotoâ&#x20AC;&#x2122;s Thyroiditis2, 3. The biliary tree is intrinsically linked to the liver and the gastrointestinal tract with 70% of the livers blood supply coming directly from the gastrointestinal tract via the portal vein, resulting in continual exposure to gut bacteria and bacterial cell contents 4.

Bile is produced in the liver and drains into the small bowel via the biliary system to aid digestion.

The pathogenesis of hepato-biliary diseases such as Primary Biliary Cirrhosis (PBC) and Primary Sclerosing Cholangitis (PSC) are thought to have an infectious trigger although studies have failed to show any significant bacteraemia in mesenteric and peripheral blood samples5. However the immune response in PBC is restricted to the epithelial cells of the intra-hepatic ducts6. It is therefore possible that bile may contain bacteria, which could trigger disease in genetically susceptible patients, especially if the bacteria are able to survive within the biliary tract and alter bile salts, which are now thought to be essential in homeostasis of the microbiota and therefore gut health7.

PBC and PSC are two of the leading causes of liver death and liver transplantation7. Both conditions present with a multitude of unpleasant symptoms and currently there is no cure for either of these conditions with the exact causes remaining unclear. Conventional wisdom dictates that bile is sterile due to the anti-microbial effects of bile salts. No studies have assessed bile from patients not known to have biliary infection or biliary disease. Studying bacteria isolated from bile samples, and seeing whether they contain any resistant properties against bile salts, helps gain an improved understanding in the pathophysiology of both conditions that could then be further investigated to implement a possible treatment pathway.

Methods Samples were obtained from the following three surgical interventions; liver resection, pancreatectomy or laparoscopic cholecystectomy. Samples were acquired from the gallbladder and biliary tract in both normal and diseased participants.

GASTROENTEROLOGY TODAY - SPRING 2018

The identity of the isolated bacteria was established by sequencing of their 16S ribosomal RNA genes. This resulted in 25 different bacterial strains being identified. The bacteria were stored as glycerols at -80°C to maintain the integrity of each strain. They were then thawed and grown in Brain Heart Infusion (BHI) media containing 0.15% bile salt concentration in order to activate bile resistance genes, which may have been switched off during storage. The bacterial strains where then exposed to bile resilience studies and then plated into quadrants using BHI medium and were counted at time 0, 24 and 48-hours. Serial dilutions were completed ranging from 0 to 10-7.

In the strains that had grown in 0.15% Bile Salts, growth in the presence of increasing concentrations of bile salts was measured using the Bio-screen C equipment.

Results In total 72 different colonies were isolated from 22 biliary samples. The majority of bacteria (49) isolated from the biliary tract were unable to replicate in the presence of bile salts. However they did survive in bile salt concentrations found within the normal biliary tract (0.15%) 1,2 for up to 48 hours, albeit in reduced numbers (table 1). The remaining 23 samples, both commensal and pathogenic, were exposed to 0, 0.2, 0.5, 1, 3, 5 and 10% bile salt concentrations. As the concentrations increased 1 Shanahan, F. (2012). The colonic microbiota and colonic disease. Curr Gastroenterol Rep, 14(5), 446-452.

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2 Le Gall, G., Noor, S. O., Ridgway, K., Scovell, L., Jamieson, C., Johnson, I. T. et al. (2011). Metabolomics of fecal extracts detects altered metabolic activity of gut microbiota in ulcerative colitis and irritable bowel syndrome. J Proteome Res, 10(9), 4208-4218.

3 Mori, K., Nakagawa, Y., & Ozaki, H. (2012). Does the gut microbiota trigger Hashimotoâ&#x20AC;&#x2122;s thyroiditis? Discov Med, 14(78), 321-326.

4. Son, G., Kremer, M., & Hines, I. N. (2010). Contribution of gut bacteria to liver pathobiology. Gastroenterol Res Pract, 2010.

POSTERS growth was inhibited, with the minimal inhibitory concentration occurring between 5 and 10%. The numbers of surviving bacteria at 10% were measured at 48 hours and although no growth was detected, the majority of bacteria had survived (table 2).

Post-bile salts

Bacterial Strains

Pre-bile salts (log10 cfu/ml)

Post-bile salts

Pre Bioscreen

(24 hours) (48 hours) (log10 cfu/ml)

(log10 cfu/ml)

Intrasporangiacae Janibacter

8.000

4.523

4.753

Janibacter Sanguinis

7.802

6.368

6.423

Paenibacillus Lactis

7.802

6.097

6.474

Bacterial Strain

(log10 cfu/ml)

Post Bioscreen (log10 cfu/ml)

Enterococcus Faecium

8.699

6.903

Citrobacter Freundii

8.336

0.000

Enterobacter Asburiae

9.125

7.368

Enterococcus

6.523

7.921

Proteus

7.894

8.501

Cronobacter Sakazakii

8.727

8.451

Enterococcus Faecalis

7.426

7.359

Stapylococcus Hominis

7.315

3.684

Staph Pasteuri

4.329

3.766

Staph Epidermidis

5.753

6.398

7.824

7.684

6.190

Bacillus Circulans

7.275

2.176

4.477

Micrococcus Luteus

7.921

5.740

5.875

Staph Epidermis

8.903

6.091

5.903

Enterococcus Faecium

9.035

6.311

4.885

Staph Epidermis

9.014

6.066

6.259

Corynebacterium Aurimucosum

6.699

3.400

4.054

Staph Pasteuri

8.125

6.166

5.620

Staph Hominis

7.301

5.190

6.308

Micrococcus Luteus

4.226

3.790

Lactobacillus Rhamnosus

8.875

6.119

6.085

Lactobacillus Rhamnosus

3.977

3.301

Table 1: Number of colonies/ml following exposure to 0.15% bile salts.

Table 2: Number of colonies/ml before and after exposure to 10% bile salts.

Conclusion The human biliary tract has its own unique microbiota. Bacteria are able to survive and thrive within this environment. The findings from this study may have important implications in the pathogenesis of liver disease. Further work such as metabolite and protein analysis needs to be done to understand the interactions of the microbiota with the host immune system and its role in health and disease to help further highlight potential pathways for the pathogenesis of disease.

GASTROENTEROLOGY TODAY - SPRING 2018

Clostridium Perfringens

5. Weismuller, T. J., Wedemeyer, J., Kubicka, S., Strassburg, C. P., & Manns, M. P. (2008). The challenges in primary sclerosing cholangitis--aetiopathogenesis, autoimmunity, management and malignancy. J Hepatol, 48 Suppl 1, S38-S57.

6. Selmi, C., Bowlus, C. L., Gershwin, M. E., & Coppel, R. L. (2011). Primary biliary cirrhosis. Lancet, 377(9777), 1600-1609.

7. Dawson, PA. Karpan, SJ. (2014). Intestinal Transport And Metabolism Of Bile Acids. J Lipid Res. Epub ahead of print.

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COMPANY NEWS

MARKET’S FIRST MOBILE DECONTAMINATION UNIT LAUNCHED EMS Healthcare’s Quest+ Decontamination will create significant efficiencies for endoscopy departments Endoscopy departments across the UK now have access to the UK’s first mobile decontamination unit, marking a ground breaking innovation for the endoscopy market that will save hospitals considerable time and money.

planning, as well as a quick solution in the face of emergency situations, aiding clinicians in the delivery of sustainable and uncompromised care.”

With the demand for gastrointestinal endoscopy set to exceed 2.4 million procedures per annum by 2019/2020, up 44 per cent since

Quest Decontamination is the latest facility from leading mobile

2013/141, Quest+ Decontamination is being introduced as growth rates

medical unit provider, EMS Healthcare, and was developed following

hit an all-time high.

+

a number of requests from healthcare providers facing increasing capacity challenges.

The unit is fully HTM compliant, featuring medical grade materials throughout. It is a completely independent facility, comprising four

Currently, in order to meet demand, healthcare providers must either use

washer disinfectors, an endoscopy grade sink and its own RO plant

external decontamination services – an expensive process that can take

on board, enabling JAG accreditation. With a footprint of 16.8m x 6m,

days to complete – or transfer the decontamination suite to a new location

Quest+ Decontamination can easily be driven on site.

within the hospital estate, which can often result in ward closures.

Keith Austin continued: “With Quest+ Decontamination we have solved a The new unit enables hospitals to continue endoscope reprocessing

major gap in the endoscopy market for a solution that enables hospitals

services without disruption for the first time, creating efficiencies either

to keep their reprocessing department running smoothly with no

when in-house decontamination is running at full capacity, department

downtime when installing new equipment or refurbishing existing facilities.

refurbishments are required, or equipment has reached the end of its eight-to-ten-year lifecycle.

“We’re proud to be pioneering the mobile medical unit sector and have already received multiple enquiries from industry leaders who have

Keith Austin, CEO at EMS Healthcare, commented: “We work closely

disclosed a real need for the unit.”

with healthcare providers to respond to their challenges and Quest+ Decontamination is a great example of our innovation in action. The unit offers hospitals a viable option for proactive equipment and capacity

GASTROENTEROLOGY TODAY - SPRING 2018

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1 http://www.cancerresearchuk.org/sites/default/files/scoping_the_ future_-_final.pdf

COMPANY NEWS

BIG CHANGES COMING SOON TO A CLINIC NEAR YOU CALPROTECTIN TESTING GOES MOBILE Written by Amanda Appleton, Product Manager, Alpha Laboratories Ltd. With the advances in technology and specifically the ubiquitous use of mobile devices developed during the last decade, a huge opportunity has arisen to change the way some healthcare services are provided. This is especially applicable to the management of chronic conditions. With most people owning a mobile device or tablet this becomes a convenient way for patients to communicate with their consultants for support and treatment advice.

NICE published a review in December 2017 (Medtech innovation briefing 132), of technologies for ‘POC and home test for calprotectin in monitoring IBD patients receiving treatment’. This states that ‘The evidence suggests that point-of-care and home-use faecal calprotectin tests have comparable accuracy to laboratory ELISA tests, but with better patient satisfaction’2.

App technology has the potential to offer a number of advantages over standard laboratory testing:

In a speech to NHS bosses in 2016, Simon Stevens (NHS England’s CEO) urged doctors, nurses and NHS managers to “grab with both

• Individually customisable

hands” the growing opportunities technology offers both to help promote

• Reduced turn-around-time for results

health and tackle the service’s chronic financial problems by saving on

• Reduced resource required

treatment and rehabilitation costs.

• Allows access to testing in remote

1

locations or whilst travelling Since publication of NICE guidance DG11 in 2013, supporting the use

• Improved compliance through privacy

of calprotectin as a cost effective method to differentiate between IBD

• Better monitoring for active patients

and IBS, the rates of calprotectin testing in the UK have increased

• Keeping well patients out of hospital

dramatically. Assays to detect calprotectin have also advanced since then to assist with changing hospital requirements. These give scalable

One solution rarely suits all; and so the

and flexible solutions that allow hospitals to evolve their calprotectin

IBDoc is customisable by individual

service in line with increasing demands.

patients to help deliver a personalised approach to monitoring:

The possibility to use calprotectin for applications other than an IBS/IBD screen have also been investigated, with many publications suggesting its usefulness in monitoring IBD positive patients for:

• The clinicians choose one of three options for patients to see when a test is completed: o Actual quantitative result (with a value between 30 - 1000µg/g) o A red, amber, green traffic light system with individually defined cut-

• Indicating mucosal healing

off values

• Predicting flares • Predicting post-operative relapse • Predicting response to biologic therapy: • Allows quicker response for optimisation when starting treatment if you monitor the calprotectin • Giving patient reassurance when switching to bio-similars to ensure the calprotectin levels don’t start to rise

useful for blinding studies or when patients need more support with the results • The threshold levels for the traffic lights are customisable to individual patients – low when in remission or higher when severe and active • The frequency of testing can also be adjusted depending on the severity of the condition. A message is sent to patients reminding them that a test is due

low • Keeping healthy patients out of the clinic

With individual customisation available, the IBDoc allows ultimate It is in this monitoring environment that the advance of mobile App

flexibility. Testing can be tailored to provide results to support clinical

technology has come to Gastroenterology; and so in 2015 the first

decision making in a range of different scenarios through remote and

CE marked calprotectin self-test was launched by BÜHLMANN in

more frequent patient monitoring, enhancing management without

the form of their IBDoc® assay system. The IBDoc allows patients to

requiring additional resource. In fact, resource could be saved, as

fundamentally use the same calprotectin testing system that many

was demonstrated in a recent poster at UEGW in Barcelona - Patients

laboratories employ (CALEX® extraction and Quantum Blue® lateral flow

starting biologics normally had a clinic appointment at 3 months and

technology). Adaptions remove the requirement for technical equipment

a colonoscopy at 6 months. However, during a study of 131 patients

so the patient can perform the test themselves in the comfort of their

starting biologics these did not take place if the calprotectin level

own home. Using the CalApp , the patient’s Smartphone becomes

determined using the IBDoc home test was below certain limits. This

the test reading device giving a quantitative result that is automatically

avoided 53 clinic visits and 62 colonoscopies with obvious cost and

transmitted to the clinic.

healthcare resource savings3.

®

GASTROENTEROLOGY TODAY - SPRING 2018

• Withdrawal of biologics but ensuring the calprotectin levels remain

o A ‘Test completed’ message with no indication of the result which is

29

COMPANY NEWS Although the number of laboratories offering calprotectin testing has increased significantly in recent years, many laboratories still perform the test in batches once a week, in order to ensure cost effective use of reagents. In smaller institutions testing is often not performed in-house, but is sent to a reference service which can then mean results take upwards of two weeks to be returned.

This delay can mean that treatment decisions have to be made without the support of the calprotectin result, or more invasive tests are performed to ultimately get the same indication.

“IBDoc is amazing and allows me to feel more in control of my Crohn’s disease. I can use it anytime to check if I’m having a flare up. It is very reassuring……………”

Patient self-testing in these situations provides same day results which can improve disease management and treatment plans, without the need for additional pathology resource. It also relieves patient anxiety, which otherwise can often have a negative effect on their condition.

Engaged patients are more likely to adhere to treatment plans which hopefully prevents illnesses from deteriorating, which often then results in more costly or invasive care. Unfortunately deterioration can still occur even when treatment plans are followed, but remote monitoring can

“Previously I had to wait more than three weeks for a result, this is a very long time to worry. Now I can just check myself at home if I am worried…………..”

assist through prompt detection, enabling intervention at an earlier point than standard testing might otherwise permit.

Although many of the studies with the IBDoc calprotectin home-test have been performed to predict flares or response to treatment in patients with moderate to severe symptoms, there is also the potential to use the technology with the patients who are experiencing mild disease or who are in remission. Using App technology to keep well patients out of hospital if they are showing low calprotectin levels, will free up limited resources and reduce waiting times for the more active patients.

The explosion of the mobile technology market means that healthcare based App’s are highly accessible as most people these days have a mobile device or tablet. This also reflects changes in lifestyle with significantly more travel undertaken for business and foreign holiday destinations becoming ever more popular. The Apps are able to transmit results back to a local portal enabling patients to stay in touch with their healthcare providers wherever they are. This helps ensure continuity of care/treatment should things deteriorate and gives reassurance for patients to travel and ‘get on with their lives’ due to the support the Apps provide. These same benefits can also be used for people living in remote locations e.g. the Scottish Highland and Islands where a routine clinic visit or even a laboratory test to help determine acute symptoms is

GASTROENTEROLOGY TODAY - SPRING 2018

30

As more clinics are adopting the use of patient self-testing for calprotectin this may start to become the norm for managing/monitoring IBD positive patients. Traditional laboratory tests may be reserved for the IBD verses IBS screen, which still accounts for approximately 80% of the workload.

App technology has the ability not only to improve the health of patients, but to save money through rapid optimisation of treatment, enable early interventions through monitoring before conditions get too serious and reduce routine check-up appointments/procedures, freeing up limited resource in both pathology and the clinic.

logistically difficult and expensive to achieve.

References

One of the big advantages of patient self-testing especially in the

1. NHS to offer free devices and apps to help people manage

gastroenterology arena is privacy. Generally people are embarrassed to take stool samples to the laboratory for testing and non-compliance is

illnesses. The Guardian 17th June 2016 2. NICE Dec 2017 Point-of-care and home faecal calprotectin tests for

often high. This is a shame, as calprotectin is well documented to give

monitoring treatment response in inflammatory bowel disease

a better indication regarding the health of the mucosa, having a higher

3. Elsafi et al 2017 UEGW. Cost effectiveness of IBDoc as a surrogate

correlation to endoscopic and histological findings than patient scores.

The calprotectin result helps to make sense of symptoms and guide treatment decisions. Being able to perform the calprotectin assay in the privacy of their own home seems to be well accepted by patients with studies quoting between 85 – 100% satisfaction/preference4,5 in testing, compared to routine laboratory tests.

marker of mucosal healing in IBD patients post induction of biologic agents 4. Raker et al 2017 ECCO Home testing for faecal calprotectin followup results from the first UK trial 5. Fitzgerald et al 2017 ECCO An evaluation of patient satisfaction with IBDoc calprotectin home test system.

Although it obviously won’t be for everyone, App technology is generally

For further information about IBDoc please visit www.alphalabs.co.uk/

perceived as fairly progressive by patients and so they have the

ibdoc or contact digestivedx@alphalabs.co.uk to discuss setting up a

potential to enhance engagement in their disease management.

trial for your clinic.

The BSG Annual Liverpool ACC Meeting 2018 4-7 June

COMPANY NEWS

The best of UK gastroenterology and hepatology Programme highlights: 53 symposia, covering all aspects of GI and liver care, exploring the latest developments in gastroenterology with hundreds of original abstracts to be presented.

Attend the Monday Masterclass: What to do when the evidence is unclear? These sessions will feature presentations from experts in the field on topics such as: “Delivering high quality colonoscopy”, “Managing severe alcoholic hepatitis” and “Severe steroid-resistant ulcerative colitis”.

On Thursday 7 June, a day of live endoscopy education will take place.

Cases from leading endoscopists will be streamed from Aintree University Hospital. This day will focus on delivering excellence in endoscopy.

Jaques Devière Erasme University Hospital, Belgium Gert van Assche University Hospitals of Leuven, Belgium Elliot Tapper University of Michigan, USA

Register now online at www.bsg2018.org

GASTROENTEROLOGY TODAY - SPRING 2018

Join us for live endoscopy:

Key speakers include:

31

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