Gastroenterology Today Summer 2018 by Media Publishing Company

28 No. 2 Volume 27

2018 Summer 2017

Gastroenterology Today In this issue The growth of Endoscopy insourcing Deciding whether or not to recommend a (Se) supplement Investigating the efficacy of the low FODMAP diet

Gastroenterology insourcing experts supporting clinical demand and capacity Driving change through highly innovative and flexible working practices

Offering rapid mobilisation with consultant-led specialist teams

Delivering significant cost and operational efficiencies in both outpatients and day surgery

Developing long term and sustainable partnerships

18 Week Support Gastroenterology: Building Expert Teams Inside: Dr Matthew Banks, 18 Week Support Gastroenterology Clinical Director on driving high quality weekend endoscopy services.

In this issue Alcohol - Health Harms Something Fishy Going On Patient Empowerment in Irritable Bowel Syndrome

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CONTENTS

CONTENTS 4

EDITORS COMMENT

FEATURE A lcohol – Health Harms

FEATURE S omething fishy going on

FEATURE S IBO and probiotics – fighting fire with fire?

NEWS

COMPANY NEWS

Gastroenterology insourcing 25 supporting FEATURE P atient Empowerment in Irritable Bowel experts clinical Syndrome demand and capacity

Gastroenterology Today This issue edited by: Dr M Goldman BSc, MBBS, MRCP, FFPM 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

Driving change through highly innovative and flexible working practices

Offering rapid mobilisation with consultant-led specialist teams

PUBLISHING DATES: February, June and October.

Delivering significant cost and operational efficiencies in both outpatients and day surgery

Developing long term and sustainable partnerships

Inside: Dr Matthew Banks, 18 Week Support Gastroenterology Clinical Director on driving high quality weekend endoscopy services.

COVER STORY

What approach has 18 Week Support taken with regards to building an expert insourcing team?

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 Autumn 2018

Matthew’s Perspective: Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. He believes it starts with recruiting the best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data is an excellent quality indicator, we now want to go a step beyond that and monitor the Non-Technical skills (NTS) of each clinician as well. We now know that NTS plays an important role in safe and effective team performance. Therefore, in our quest to develop excellent teams who deliver a world-class service, we must focus on NTS’.

Tammy Kingstree is Lead Nurse for Endoscopy. ‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from our senior nurse coordinators who are trained to manage the patient pathway, manage a team of staff they may not know and to deal effectively with any issues which may arise on the day’. Lisa Phillips is Lead Nurse for Endoscopy. ‘The team objectives are clear. Excellent patient experience and good patient outcomes. Because the objectives are clear, team cohesion and focus are exceptionally good. It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit, the service should be seamless. If it isn’t, we do not stop until we get it right. For more information please contact: Alex Chilvers, Operations Director on 02038698793 or visit www.18weeksupport.com

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GASTROENTEROLOGY TODAY - SUMMER 2018

Tammy and Lisa’s Perspective:

Subscription Information – Summer 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.

EDITORS COMMENT

EDITORS COMMENT The end of the road

GASTROENTEROLOGY TODAY - SUMMER 2018

“The introduction of endoscopic examinations via every orifice, and imaging techniques that capitalised on the advances in information technology have improved the precision and sensitivity of diagnosis for many pathologies.”

This year marks the 50th Anniversary of my personal engagement with the medical profession, and I have decided to call it a day and go out on a high. Like so many things, it is a different world to the day I started out on this quest. Back in those days, admission to medical school seemed more unpredictable. There were individuals who were given university offers of ‘3 E’s’, and stories of men who were recruited on the basis of their ability to catch a rugby ball. Apart from one medical school, women were in a minority (about 20% in my year) and the demographics heavily favoured pupils of public schools with medical parents. Progress through training, particularly the separate clinical years, was somewhat unstructured, and there was a fashion with some consultants for teaching by humiliation of the student. IT simply did not exist, and it was a world dominated by pen and ink. By the time I graduated, changes to the very patriarchal system of progress were being hinted, and in my first house job, there was a national doctors’ work to rule over plans by the government to minimise overtime payments (no 40 hour weeks then and working time directives), which included the idea that the first four hours of overtime should be worked for no payment. This was followed a couple of years later by the ‘Winter of discontent’ where I learned that being a member of a healthcare trades union (not the BMA) gave the hospital ancillary staff a level of industrial muscle that forever changed the pecking order in hospitals. Change, sometimes apparently for the sake of change, has been the pattern of practice in the health service. It became a victim of its own effectiveness with new perspectives and progress in practice. Expectations from the delivery of health care have outstripped the ability of any government to pay for, and the managed care programmes seen in other economies have not necessarily done any better. Whilst some of what I learned was the black art of consensus (covered by the phrase ‘it is generally agreed’) the introduction of evidence based/governed practice has removed some of the innate skills that came with years of training. At least we now have big data to support the decisions that we are expected to take. Having said that, there have been some remarkable diagnostic and therapeutic advances that fundamentally changed the way that patients are managed. The introduction of endoscopic examinations via every orifice, and imaging techniques that capitalised on the advances in information technology have improved the precision and sensitivity of diagnosis for many pathologies. One of the most fascinating changes has been the shift in diagnosis and management of peptic ulcer disease. In my training, diagnosis was dominated by radiology followed by forms of surgery around the upper GI tract, and then potentially followed by consequences of the surgery. No one would have guessed that it might have been an infectious disease, treatable by receptor blocking and antibiotics, rendering hours of retractor pulling redundant. It is the nature of retrospectoscopes to focus on the rose tinted, and to view changes with suspicion. One of the things that consistently features in the recollections of my peers is that there was a lot of fun to be had whilst working, and the glue that held professional colleagues together has been weakened by the removal of the old style teams. Gone are the golden days of the Doctors’ Mess and resident staff. Whilst those who had jobs that physically and mentally exhausted them may have welcomed the limitation of working hours, discontinuity is, I promise you, something that bothers patients. The most fulfilling role I had during my working life was that of appraiser for the relatively recently introduced revalidation and re-licensing of doctors who want a licence to practice in the UK. Whilst I did not always agree with the one-size-fits all approach to the methodologies of appraisal, I recognised that at last there was an opportunity for mentoring professionals in a way to help minimise the risks and maximise professional advancement. I know that I have helped some individuals over sticky patches in a way that was never available to the sink-or-swim approach that existed in the past. So I guess that some changes are occasionally for the better. It also helped me recognise that you have to draw your own line in the sand and I have drawn mine. It was good while it lasted, but enough is enough, and I was to determined to not go from work to dead without collecting the money. If any of you ever have to deal with me as a patient in the future, please be kind to me, as I really did try to do the best I could. Dr M Goldman BSc, MBBS, MRCP, FFPM, Editor

PUBLISHERS COMMENT Having been the co-editor of Gastroenterology Today since its launch in 1990, Martin Goldman has decided it is time to step down, his contribution and enthusiasm will be sadly missed as the role at times has been challenging to say the least! On behalf of everyone at Media Publishing and those involved with this publication, I would personally like to thank Martin for playing an important part in the publication’s growth over the years and wish both him and his family an enjoyable future. Terry Gardner, Publisher, Gastroenterology Today

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Pancreatic Cancer

PEI Think PEI Chronic Pancreatitis

Cystic Fibrosis

Diabetes

The online resource for healthcare professionals who would like to learn more about PEI, its causes and management Pancreatic exocrine insufficiency (PEI), is a condition in which people are unable to adequately digest fats, carbohydrates and proteins due to a lack of digestive enzymes being produced from the pancreas. This results in nutrient malabsorption and malnutrition, which can have further consequences for patients.1 Reference 1. Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol. 2017;23(39):7059-7076. NON-2018-0165 Date of preparation: February 2018

FEATURE

ALCOHOL – HEALTH HARMS, ORGAN SUSCEPTIBILITY AND THE UK CHIEF MEDICAL OFFICER’S 2016 DRINKING GUIDELINES Authors: Avanti Pandit BSc, Medical Student, University of Manchester Kieran J. Moriarty MD, FRCP, FRCPI, Consultant Gastroenterologist, Bolton NHS Foundation Trust Corresponding Author: Kieran J. Moriarty MD, FRCP, FRCPI, Consultant Gastroenterologist, Bolton NHS Foundation Trust, Bolton, BL4 0JR, England E-mail: Kieran.Moriarty@boltonft.nhs.uk

Key Words Alcohol, Health Harms, Organ Susceptibility, 2016 UK Drinking Guidelines

Hence, there is theoretically no concentration limit in body water. Ethanol is absorbed from the stomach and small intestine and is distributed throughout the body, with most tissues being exposed to the same concentration as the blood. However, the liver receives greater exposure, since blood is received directly from the stomach and small intestine. 90-95% of ethanol is metabolised by the liver, with some

Abstract Alcohol is included in 30 International Classification of Diseases (ICD)-10 codes and is a component cause for more than 200 ICD10 disease codes. Ethanol is oxidised to acetaldehyde, which is

excreted unchanged in urine, breath or sweat. Ethanol is oxidised by alcohol dehydrogenases (ADH) to acetaldehyde, which is toxic and carcinogenic. This is rapidly oxidised by aldehyde dehydrogenases (ALDH) to harmless acetate, which is oxidised in liver and tissues to carbon dioxide and water [5].

toxic and carcinogenic. Alcohol causes toxic effects on organs and tissues, intoxication and dependence. The liver is especially vulnerable, since it is the primary site of alcohol metabolism. In 2016, the UK’s Chief Medical Officers launched new evidence-based drinking guidelines. They concluded that, for both men and women, to keep health risks from alcohol to a low level, it is safest not to regularly drink more than 14 units a week. There is no ‘safe level’ of consumption, and the risk of developing certain cancers increases directly in line with consumption of any amount of alcohol. Women, who are pregnant, or planning a pregnancy, are advised to abstain. Moreover, there is no justification for recommending drinking, or for starting drinking, for health reasons.

Mechanisms of alcohol-related harm Alcohol causes acute and chronic harmful anatomical and pathophysiological harm by three mechanisms, namely toxic effects on organs and tissues, intoxication and dependence. Health outcomes, including death, disease, socioeconomic consequences and harm to others, are determined by the volume and quality consumed and patterns of drinking. Individual vulnerability factors include age, gender, familial factors and socioeconomic status. Societal vulnerability factors include economic development, culture,

Introduction

drinking context and alcohol production, distribution and regulation. Availability of alcohol and the extent and efficacy of alcohol policies determine individual and population level differences in consumption and related harm [1]. Alcohol is linked both to the incidence of, and the

10 codes, consumption being a necessary cause for that disease.

course of disease [Figure 1].

Alcohol use disorders (AUDs) are the most significant. Moreover, alcohol is a component cause for more than 200 ICD-10 disease codes.

Heavy episodic drinking (HED) is defined as drinking 60 grams or

A component cause may be one among a number of components,

more of pure alcohol on at least one occasion in the past seven days.

none of which alone is sufficient to cause the disease [1]. Historically,

Globally, consumption is usually expressed in grams of alcohol. In the

studies have usually examined the effect of moderate to high alcohol

2016 UK Chief Medical Officers’ Alcohol Guidelines Review, one unit

consumption on organ damage. Rehm et al found a low threshold, dose-

contains 8 grams or 10 millilitres of pure alcohol [3, 4].

dependent relationship for certain diseases [2]. This paper reviews the health harms of alcohol, organ susceptibility and the evidence-base for the 2016 UK Chief Medical Officers (CMOs)’ Drinking Guidelines [3, 4].

Alcohol metabolism

Gender Women have less body water than men to dilute ingested alcohol, lower body weight, less gastric alcohol dehydrogenase, smaller metabolic liver capacity and more body fat, which absorbs alcohol poorly. Hence, women have

Alcohol (ethanol) is infinitely soluble in water and freely diffusible.

GASTROENTEROLOGY TODAY - SUMMER 2018

Alcohol is included in 30 International Classification of Diseases (ICD)-

increased serum alcohol levels from the equivalent amount consumed [1, 5].

FEATURE

Alcohol-related mortality and burden of disease and injury Alcohol-specific mortality includes deaths from a cause wholly attributable to alcohol. AUDs and Foetal Alcohol Syndrome (FAS) are 100% attributable to alcohol. Alcohol-related mortality includes deaths which are wholly or partially attributable to alcohol. Alcohol-attributable

of alcohol and drinking patterns. Young people, who drink heavily once a week, are most likely to die from an alcohol-related condition. The risk of death is lower in people of all age groups, who drink daily, compared to those who drink the same volume in one day [Figure 3]. In the UK, the net protective effect on mortality is significant only for women aged 55+, drinking around one unit per day, with men aged 55+ showing negligible net protective effect [3, 4].

fractions (AAFs) represent the proportion of diseases, deaths or burden of disease and injury that is attributable to alcohol.

Methodology

Disability-adjusted life years (DALYs) represent a measure of overall disease burden. DALYs are the combination of years of life lost due

The literature review accessed the electronic journal databases,

to premature mortality and to those lived in less than full health. The

PubMed and Google Scholar. Search terms were in the English

impact on DALYs is more pronounced than on mortality since alcohol-

language, using the key word “alcohol”, followed by a specific organ.

attributable deaths occur relatively early in life, resulting in many years GASTROENTEROLOGY TODAY - SUMMER 2018

lost due to premature mortality, and AUDs are often very disabling [1]. The proportion of all global deaths and burden of disease caused by alcohol consumption, i.e. AAFs, is shown [Figure 2].

of alcohol consumed were referenced.

Alcohol and individual organ susceptibility Cardiovascular

Alcohol and all-cause mortality The “J-shaped relationship” between alcohol consumption and all-cause mortality is much debated. The “protective” effect of “light” drinking has

Cardiovascular Disease (CVD) Alcohol consumption has a J-shaped or U-shaped association with cardiovascular mortality and disease burden. Most studies

been increasingly questioned, since consumption has been estimated,

have shown that, compared with non-drinkers, “moderate” alcohol

often retrospectively and inaccurately, at a single time point, and non-

consumption is associated with a lower risk of morbidity and mortality

drinker “control” groups have included ex-drinkers, or “sick quitters”,

from cardiovascular disease, as well as more favourable cardiovascular

and also “ill abstainers”, who may have increased mortality [3, 4].

disease profiles [6, 7, 8, 9]. However, non-drinkers have often included the confounding groups, namely “sick quitters” and “ill-abstainers”, both

Relative risk of death increases in both genders with mean consumption

Generally, articles published in the last 10 years with specific quantities

of which have increased cardiovascular morbidity and mortality.

FEATURE

Regular consumption of 2.5g-14.9 grams/day was associated with a 14-

aggregation, fibrinogen and lipoprotein, and increased HDL cholesterol

25% reduction in CVD, but 60 grams/day significantly increased the risk,

and tissue plasminogen activator and improved endothelial function

compared to non-drinkers [6, 12, 13].

[10]. The protective effects of light drinking are cancelled out by irregular HED and do not occur in Asian, Indian, Chinese and Afro-American

There is J-shaped relationship between alcohol consumption and risk

populations [7]. Moreover, genetic studies suggest that reducing even

of stroke. In men, the relative risks of death from ischaemic stroke

light or moderate consumption, may improve cardiovascular health [11].

decreased by 11% if drinking regularly at 2 units (16 grams) per day

GASTROENTEROLOGY TODAY - SUMMER 2018

Potential beneficial mechanisms include decreased platelet

FEATURE and increased by 3% if drinking regularly at 5 units (40 grams) per day [4]. For haemorrhagic stroke, drinking 12 grams/ day was associated with a 17% risk reduction, whereas drinking more than 60 grams/day was associated with a 64% increased risk [13]. A large scale study of 1.93 million adults, without cardiovascular disease at baseline, showed that moderate drinking was associated with a lower risk of initial presentation with several, but not all, cardiovascular diseases, even after separation of groups of nondrinkers. Whilst higher consumption was associated with a lower risk of initial presentation with myocardial infarction, this was offset by heavier drinkers having an increased risk of initially presenting with several other cardiovascular diseases and death from non-cardiovascular causes [14]. Hypertension Alcohol consumption has a linear relationship with hypertension in men [15, 16]. In women, there is a J-shaped relationship, with increased risk at 15 grams/day [16]. Alcohol exacerbates pre-existing hypertension [17]. In regular drinkers, blood pressure increases by approximately 1.5mm Hg for every 10g/ day consumed. This is reversible with 2-4 weeksâ&#x20AC;&#x2122; abstinence [17]. Arrhythmias Alcohol consumption, especially HED, affects cardiac conduction. Atrial fibrillation (AF), atrial flutter, paroxysmal GASTROENTEROLOGY TODAY - SUMMER 2018

AF, other supraventricular arrhythmias and Holiday Heart Syndromes [18] are well recognised. Torsades de pointes, a ventricular tachycardia with QT interval prolongation and risk of sudden death, is associated with acute alcohol consumption [19]. For cardiac arrhythmias, for men, the relative risks of illness and death increase by 13% if drinking regularly at 2 units (16 grams) per day and by 34% if drinking regularly at 5 units (40 grams) per day [4].

Cardiomyopathy Alcohol-related cardiomyopathy (ACM) results from the toxic effects of ethanol and its metabolites on cardiac muscle, calcium homeostasis, myocardial protein and lipid synthesis and signal transduction, with degeneration of myofibrils and fibrosis [21]. Liver The liver is especially vulnerable, since it is the primary site of alcohol metabolism. Alcohol-related liver disease (ARLD) and the risk of cirrhosis illness and death are related to the dose and duration of

At the 2015 Munich Octoberfest, acute alcohol consumption, in young

consumption [22].

people, who received a smartphone-based ECG and breath alcohol concentration measurements, was associated with cardiac arrhythmias

60-100% of persistent heavy drinkers develop steatosis (fatty liver),

(31%), especially sinus tachycardia (26%), partly reflecting autonomic

20-40% steatohepatitis, 10-20% fibrosis or cirrhosis and 3-10%

imbalance, as assessed by significantly reduced respiratory sinus

hepatocellular cancer. Steatosis and steatohepatitis may be reversible

arrhythmia [20].

with abstinence. Cirrhosis is largely irreversible [23]. Approximately 15-

FEATURE 20% of patients consuming 160 grams/day for 8 years develop cirrhosis

Amblyopia is related to heavy tobacco and alcohol abuse [34]. Central

[24]. In men, the relative risks of death from cirrhosis increase by 57% if

pontine myelinolysis (CPM) is caused by severe damage to the myelin

drinking regularly at 2 units (16 grams) per day and by 207% if drinking

sheath of pontine nerve cells. It occurs with heavy consumption,

regularly at 5 units (40 grams) per day [4].

sometimes with severe hyponatraemia. If corrected rapidly, CPM may result. Marchiafava–Bignami disease is a progressive neurological

Risk is higher in smokers and in patients with malnutrition, obesity or

condition in chronic heavy drinkers, characterized by demyelination of

hepatitis C, in whom there can be a “double-hit” to the liver from ARLD

the corpus callosum, necrosis and atrophy [35].

and non-alcoholic fatty liver disease and hepatitis C respectively. For a person with a BMI of >35, the risk of liver disease doubles at any given

Musculoskeletal

alcohol intake [25]. In cirrhosis from any cause, mortality becomes

A dose-dependent relationship between alcohol consumption and bone

pronounced with even moderate consumption [24].

mineral density has been established. Daily consumption of 5-24 grams has been associated with an increased risk of osteoporosis. Chronic

Gastrointestinal

consumption inhibits osteoblast activity and reduces osteocalcin,

Alcohol impairs the lower oesophageal sphincter, precipitating

predisposing to osteoporosis. ARLD causes abnormal vitamin D

gastroesophageal reflux disease [26]. A Spanish study reported a 2.5

metabolism, impairing calcium absorption and bone formation [36].

fold increased risk of developing GORD with an alcohol consumption of ≥ 200 grams/week. Consumption of 60 grams/day led to a 3.3 fold

Alcohol impairs muscle protein synthesis in a dose-dependent manner,

increase in the risk of developing duodenal ulcers, but not of gastric

although myopathy may be reversible on abstinence [37].

ulcers [27]. Diabetes, Endocrine, Metabolism Alcohol contains 7 kcal/gram and displaces normal nutrients, causing

For Type 2 diabetes mellitus (DM), light drinking has been associated

malnutrition. Daily consumption of 40 grams/day in men and 20

with reduced risk and heavy drinking with increased risk [38]. However,

grams/day in women may cause small intestinal mucosal damage,

a meta-analysis found no reduction at any level of consumption in

malabsorption and intestinal dysmotility. Alcohol concentrations

men. In women, there was reduced risk at less than 61 grams/day

are highest in the jejunum and duodenum, where haemorrhagic

[39]. However, consumption of 24 grams/day in diabetic patients

lesions occur. Alcohol impairs absorption of D-glucose, L-amino

increased the risk of acute coronary syndromes 10-fold, myocardial

acids, monoglycerides, fatty acids, thiamine and essential vitamins

infarction 8-fold and unstable angina 13-fold. Heavy consumption also

and micronutrients and can increase faecal bacteria in the gut flora

exacerbated diabetic complications, including nephropathy, neuropathy,

[28]. Alcohol has a dose- and duration-dependent effect for chronic

non-alcoholic steatohepatitis (NASH) and retinopathy [40]. The

pancreatitis in both genders and for acute pancreatitis in men. For acute

endocrine and metabolic effects are shown [Table 1].

pancreatitis in women, the risk increases at 40 grams/day, lower doses being protective [29].

Haematological Macrocytosis, with or without anaemia, is common in chronic, heavy

Respiratory

consumers. Anaemia can be due to direct toxic effects on erythropoiesis

Alcohol consumption is associated with tuberculosis and pneumonia,

and to gastrointestinal haemorrhage and haemolysis. Leukopenia and

due to aspiration, S. pneumoniae, Respiratory Syncytial Virus (RSV),

thrombocytopenia are associated with hypersplenism [41].

Klebsiella, Pseudomonas and Actinobacter. Chronic consumption changes the upper respiratory tract flora, facilitating gram-negative

Renal

bacterial colonisation, which causes ciliary and alveolar macrophage

Alcohol consumption is associated with kidney disease, often mediated

dysfunction, compromising innate and acquired immunity. This

by hypertension. Alcohol is a strong risk factor for glomerulonephritis,

exacerbates asthma and COPD and increases the risk of acute

acute kidney injury and kidney graft failure. There is a J-shaped

respiratory distress syndrome [30].

association between alcohol consumption and kidney function, with 11-

Nervous System

for kidney function [42].

Alcohol can cause acute intoxication, epilepsy, Wernicke Korsakoff Syndrome and irreversible alcohol-related brain damage (ARBD).

Skin

Compared with abstinence, moderate alcohol intake was associated

There is an association between psoriasis and alcohol consumption

with increased adverse brain outcomes, especially hippocampal atrophy

[43]. Fungal infections occur with neglect.

and steeper cognitive decline. No protective effect was found for small amounts of alcohol over abstinence [31].

Immune System and Infections Alcohol impairs macrophage and monocyte function. Chronic

Cognitive function was impaired in 19-21 year olds, who drank 64

consumption changes the microbiome in the gut and lungs,

grams/week, compared to non-drinking peers [32]. Alcohol-related

reducing neutrophil phagocytosis and interferon production. Chronic

peripheral neuropathy (ARPN) may be related to thiamine deficiency

consumption impairs T-cell and B-cell responses. Alcohol consumption

or to direct neurotoxicity. Small fibre neuropathy was detected in men

is associated with increased risk of contracting HIV (and also non-

consuming ≥ 70 grams/day and in women consuming ≥ 56 grams/

adherence to treatment), sexually-transmitted diseases, Hepatitis C,

day [33].

pneumonia and Mycobacterium tuberculosis [44].

GASTROENTEROLOGY TODAY - SUMMER 2018

27 grams/day for women and 11-40 grams/day for men being optimal

FEATURE CARDIOVASCULAR

MUSCULOSKELETAL

REPRODUCTIVE SYSTEM

Coronary Artery Disease

Osteoporosis

Menstrual disorders

Acute Alcohol Withdrawal

Arrhythmias:

Myopathy

Ovulation disorders

Perioperative problems

Rhabdomyolysis

Impaired Conception

Cross-tolerance to anaesthetics

Atrial fibrillation Atrial flutter Holiday Heart Syndrome

DIABETES, ENDOCRINE, METABOLISM

Impaired Sperm production

Autonomic dysfunction

Loss of libido

Impaired wound, skin, bone healing Increased Infections

Ventricular

Obesity

Impotence

Torsades de pointes

Diabetes mellitus Type 1

Testicular atrophy

Anastomosis leak

Sudden death

Diabetes mellitus Type 2

Gynaecomastia

Increased length of stay

Cardiomyopathy

Alcohol-related ketoacidosis

Loss of body and pubic hair

Increased mortality

Hypertension

Hyponatraemia

Congestive Cardiac Failure

Hypokalaemia

PREGNANCY COMPLICATIONS

PERSONALITY AND MOOD

Beri beri

Pseudo Cushing’s syndrome

Spontaneous Abortion

Reduced Inhibitions

Ischaemic Stroke

Inhibited secretion of ADH

Stillbirth

Anxiety

Haemorrhagic Stroke

Beer Water Intoxication

Pre-term delivery

Depression-Unipolar or Bipolar Paranoia

LIVER

Hyperlipidaemia

Reduced foetal growth

Fatty Liver (Steatosis)

Zieve’s syndrome

Reduced birth weight

Aggression

Steatohepatitis

Hypocalcaemia

Foetal Alcohol Syndrome

Loss of self-esteem

Cirrhosis

Hypomagnesaemia

Foetal Alcohol Spectrum Disorder

Suicidal Ideation and Suicide

Hepatocellular Cancer

Hypophosphataemia

GASTROINTESTINAL

Reduced Vitamin D3 Absorption

CANCER

TOLERANCE

Malnutrition

Reduced serum zinc

Oropharynx

Increased liver metabolism Increased risk of organ damage

Anorexia

Gout

Larynx

Nausea and Vomiting

Scurvy

Oesophagus

Gastrooesophgeal Reflux Mallory Weiss tear

HAEMATOLOGICAL

Oesophageal rupture

Anaemia:

Female Breast

COMBINATION USE

Liver

Smoking

Colorectal

Cannabis

Iron deficiency

Stomach

Amphetamines

Varices

Megaloblastic

Pancreas

Cocaine

Gastritis

Haemolytic

Lung

Sedatives

Gallbladder

Opioids Intravenous Alcohol

Gastrointestinal haemorrhage

Peptic ulcers

Macrocytosis

Acute Pancreatitis

Leucopenia

Chronic Pancreatitis

Thrombocytopenia

VIOLENCE AND INJURIES Road Accidents

Polysubstance abuse

Malabsorption

Folate deficiency

Diarrhoea

Coagulopathy

Workplace Accidents

YOUNG PEOPLE VULNERABILITY

Haemorrhoids

Haemosiderosis

Falls

Other substance use

RESPIRATORY Pneumonia

Rib fractures

Sexually transmitted diseases

RENAL

Assaults

Unsafe and regretted sex Sexual assault

COPD

Glomerulonephritis

Facial Injuries

Asthma

Acute Kidney Injury

Burns

Unplanned pregnancy

Tuberculosis

Chronic Kidney Disease

Fire Deaths

Cognitive impairment

Respiratory Distress Syndrome

End Stage Renal Disease

Drownings

Later life dependence

Aspiration Pneumonia

Loin Pain

Self harm

Impaired reproductive function

Suicide

Criminal record

Lung abscess

Pelvi-ureteric obstruction

Bronchiectasis

IgA Nephropathy

NERVOUS SYSTEM

Myoglobinuria from Rhabdomyolysis

ALCOHOL WITHDRAWAL SYNDROME

Amblyopia

Renal Graft failure

Associated with Dependence

Night blindness Subdural haematoma

SKIN

Reduced job prospects OLDER PEOPLE VULNERABILITY

Anxiety

Stigma

Tremors

Atypical presentation

GASTROENTEROLOGY TODAY - SUMMER 2018

Extradural haematoma

Psoriasis

Paranoia

Failed recognition

Blackouts

Discoid Eczema

Hallucinations

Reduced total body water

Epilepsy

Acne rosacea

Delirium tremens

Reduced lean body mass

Asphyxiation

Fungal infections

Convulsions

Reduced gastric alcohol dehydrogenase

Death

Malnutrition

PHYSIOLOGICAL RESPONSES

Hypothermia

Respiratory depression Coma

IMMUNE SYSTEM AND INFECTIONS

Brain damage

Impaired Immunity

Falls

Impaired memory, planning, judgment

Pneumonia

Hypoglycaemia

Immobility

Anterograde amnesia

Tuberculosis

Insomnia

Incontinence Self-neglect

Dementia

HIV and AIDS

Drowsiness

Wernicke Korsakoff Syndrome

Non-Adherence to HIV treatment

Impaired Vision and Hearing

Social isolation

Cerebellar degeneration

Septicaemia

Ataxia

Interactions with medications

Hepatic Encephalopathy

Urinary tract infection

Facial flushing

Prescribed

Peripheral Neuropathy

Biliary sepsis

Hypothermia

Over-the-counter

Neuropraxia

Spontaneous Bacterial Peritonitis

Diuresis

Radial nerve injury (Saturday Night Palsy) Compartment Syndrome Central Pontine Myelinolysis Marchiava-Bignami disease

SURGICAL AND ANAESTHETIC

Table 1: Alcohol – Health Harms, Associations and Organ Damage

Dehydration

Dual diagnosis

FEATURE Reproductive System

Key messages for both men and women include:

Alcohol is associated with infertility. Consumption of 12-60 grams/ week in women reduces conception [45]. In men, alcohol consumption increases morphologically abnormal sperm and seminal leukocyte concentrations and reduces seminal volume [46].

• To keep health risks from alcohol to a low level, it is safest not to drink more than 14 units a week on a regular basis • Women, who are pregnant, or planning a pregnancy, should be advised that the safest approach is not to drink alcohol at all

Pregnancy Complications Alcohol readily crosses the placenta, is teratogenic and eliminated by

• The risk of developing a range of cancers increases directly in line with consumption of any amount of alcohol

maternal metabolism. Consumption in pregnancy is associated with

• There is no such thing as ‘a safe level’ of alcohol consumption

a range of lifelong conditions, the Foetal Alcohol Spectrum Disorders

• There is no justification for recommending drinking on health

(FASD) [1]. Consumption of 8-16 grams/day increases the risks of low

grounds, or for starting drinking for health reasons.

birth weight, preterm birth and being small for gestational age, which rise with increasing consumption. An increased likelihood of child behaviour problems was noted following prenatal exposure to less than 72 grams/week. Drinking more than 12 grams/day is associated with an increased risk of early miscarriage [4]. Cancer Alcohol consumption is associated with an increased, often doseresponse risk of cancer of the oropharynx, larynx, oesophagus, colon, rectum, liver and female breast [47]. There is no safe or threshold dose for certain cancers, including female breast cancer. The relative risks of illness and death from female breast cancer increase by 16% if drinking regularly at 16 grams/day and by 40% if drinking regularly at 40 grams/ day [4]. Violence and Injuries Alcohol consumption, especially HED, is linked to intentional and unintentional injuries. Unintentional injuries are strongly linked to blood alcohol concentrations and impaired psychomotor function. High alcohol consumption creates an exponential increase in risk [48].

Discussion Alcohol causes a major burden in four areas, crime and social disorder, families and family networks, the workplace and to health. Public Health England estimated the annual cost to be between 1.3% and 2.7% of annual GDP, which equates to between £27 billion and £52 billion [16]. The report provides the evidence-base for population measures, including taxation, regulation of price, marketing and availability, information and education and reducing drink-driving. Lifestyle measures to address liver disease have been highlighted [54]. Brief interventions and hospital alcohol care teams help patients achieve abstinence, reverse or improve health harms and prognosis, remove the stigma of self-inflicted disease, restore self-respect and return patients to their families [55]. Our paper highlights the 2016 UK Chief Medical Officers’ Alcohol Guidelines Review, exploding the myth of beneficial “moderate” drinking and describes the harmful, including carcinogenic effects of even “low”

Personality and Mood

levels of alcohol consumption on virtually every organ system in the

The presence of either AUD or depression doubles the risk of the

body.

second disorder [49]. Bipolar disorder affects around 3% of people Conflicts of interests: Dr Moriarty is the Alcohol Lead for the British

association between AUD and suicidal ideation, attempted or

Society of Gastroenterology and an Executive Member of the Alcohol

completed suicide [51].

Health Alliance UK.

Additional health harms

Author contributions: Dr Moriarty conceived the review, revised

In addition to individual organ system damage, alcohol consumption is

several drafts and agrees to be accountable for all aspects of the work.

associated with a large number of physiological and social complications.

Avanti Pandit acquired the data, drafted and revised several drafts and

These include alcohol withdrawal syndrome, physiological responses,

agrees to be accountable for all aspects of the work.

surgical and anaesthetic complications, tolerance, combination use, young people vulnerability and older people vulnerability. These and other

Acknowledgements: The authors are grateful to Ms Paula Elliott,

health harms, associations and clinical features are shown in Table 1. The

Librarian, Bolton NHS Foundation Trust, for checking the references.

male-female gender gap in indicators of alcohol use and related harms is closing, especially in young adults [52]. Alcohol and Smoking Alcohol and smoking have a synergistic harmful effect in increasing the risk of heart disease, stroke and cancer, especially aerodigestive cancers [53]. UK Chief Medical Officers’ Alcohol Guidelines Review In 2016, the UK’s Chief Medical Officers launched new alcohol evidence-based drinking guidelines, following a comprehensive, independent review [3, 4].

References 1. World Health Organisation (WHO). Global status report on alcohol and health - 2014. Geneva: World Health Organisation, 2014. Available online at apps.who.int/iris/ bitstream/10665/112736/1/9789240692763_eng.pdf?ua=1 [accessed 18 January 2018]. 2. Rehm J, Baliunas D, Borges GL, Graham K, Irving H, et al. The relationship between different dimensions of alcohol consumption and burden of disease: an overview. Addiction 2010; 105(5):817-43.

GASTROENTEROLOGY TODAY - SUMMER 2018

and co-exists with AUD in up to 13% [50]. There is also a significant

FEATURE

UEG Week Vienna 2018 October 20-24, 2018 Venue: Austria Center Vienna

Late breaking ion abstract submiss , opens August 20 2018

Ahead of UEG Week Vienna 2018, UEG President Professor Paul Fockens discusses why he is looking forward to one of the world’s premier digestive health meetings. With more than 13,000 attendees from across the globe, UEG Week is one of the largest gastroenterology and hepatology meetings in the world. This year’s congress will take place at the heart of Europe in Vienna, the home of UEG. A world-class programme has been carefully pieced together by my colleagues in the UEG Scientific Committee, featuring the latest advancements in clinical management and the best new research in digestive health. The programme boasts a variety of symposia and session types to ensure that a comprehensive offering is provided for all attendees, whatever their specialty may be.

GASTROENTEROLOGY TODAY - SUMMER 2018

The congress kicks-off with the Postgraduate Teaching Programme, comprising of two days of excellent medical education and state-ofthe-art sessions. The interactive session formats will include tricky clinical cases, controversial debates and exciting video cases, supplying a perfect mix for both gastroenterologists in training and established physicians.

UEG Week will once again host the hugely successful ‘Today’s Science, Tomorrow’s Medicine’ initiative and this year’s theme will focus on regenerative medicine in digestive diseases. This symposium series is constructed through a combination of invited speaker and Free Paper sessions, ensuring the world’s leading scientists and young researchers unite to help shape future developments in our dynamic field. Science is at the forefront of UEG Week and we are constantly looking to attract the best science and research to our congress. The meeting provides a fantastic opportunity for researchers around the world to submit and present their latest research findings and, to support the quality of submissions, UEG offer a number of awards, including the Top Abstract Prize and the UEG Rising Stars Awards. I am anticipating a very exciting week of scientific advances and updates from leading digestive health experts and, along with my fellow colleagues, look forward to welcoming new and returning delegates to UEG Week Vienna 2018.

To find out more, visit www.ueg.eu/week

Benefit from redu registratio ced n fees before Sept. 6, 2 018

FEATURE 3. Holmes J, Angus C, Buykx P, Ally A, Stone T, et al. Mortality and morbidity risks from alcohol consumption in the UK: Analyses using the Sheffield Alcohol Policy Model (v.2.7) to inform the UK Chief Medical Officers’ review of the UK lower risk drinking guidelines. Final report. Sheffield: University of Sheffield, 2016. Available online at www.shef.ac.uk/polopoly_fs/1.538671!/file/Drinking_Guidelines_ Final_Report_Published.pdf [accessed 18 January 2018]. 4. Department of Health. Alcohol Guidelines Review – Report from the Guidelines Development Group to the UK Chief Medical Officers. London: Department of Health, 2016. Available online at www. gov.uk/government/uploads/system/uploads/attachment_data/ file/489797/CMO_Alcohol_Report.pdf [accessed 18 January 2018]. 5. Cederbaum AI. Alcohol metabolism. Clin Liver Dis 2012;16(4):667-85. 6. Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ 2011; 342:d671. 7. Roerecke M, Rehm J. Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers. BMC Med 2014; 12:182. 8. Roerecke M, Rehm J. Ischemic heart disease mortality and morbidity rates in former drinkers: a meta-analysis. Am J Epidemiol 2011; 173(3):245–58. 9. Roerecke M, Rehm J. The cardioprotective association of average alcohol consumption and ischaemic heart disease: a systematic review and meta-analysis. Addiction 2012; 107(7):1246–60. 10. Fernandez-Sola J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. Nat Rev Cardiol 2015; 12(10):576-87. 11. Holmes MV, Dale CE, Zuccolo L, Silverwood RJ, Guo Y, et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ 2014; 349:4164. 12. Mukamal KJ, Conigrave KM, Mittleman MA, Camargo CA, Stampfer MJ, et al. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. N Engl J Med 2003; 348(2):109-18.

19. Dessertene F. Ventricular tachycardia with two variable opposing foci. Arch Mal Coeur Vaiss 1966; 59:263-72. 20. Brunner S, Herbel R, Drobesch C, Peters A, Massberg S, et al. Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Octoberfest: results from the Munich Beer Related Electrocardiogram Workup Study (MunichBREW). Eur Heart J 2017; 0: 1-7 doi:10.1093/eurheart/ehx156. 21. Iacovoni A, De Maria R, Gavazzi A. Alcoholic cardiomyopathy. J Cardiovasc Med (Hagerstown) 2010; 11(12):884-92. 22. Rehm J, Taylor B, Mohapatra S, Irving H, Baliunas D, et al. Alcohol as a risk factor for liver cirrhosis: a systematic review and metaanalysis. Drug Alcohol Rev 2010; 29:437−45. 23. Kendrick S, Day C. Natural history and factors influencing the course of alcohol-related liver disease. Clin liver disease 2013; 2: 61-63. doi: 10.1002/cld.145. 24. Liangpunsakul S, Haber P, McCaughan GW. Alcoholic Liver Disease in Asia, Europe, and North America. Gastroenterol 2016; 150(8):1786-97. 25. Hart CL, Morrison DS, Batty GD, Mitchell RJ, Davey Smith G. Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. BMJ 2010; 340:c1240. 26. Teyssen S, Singer MV. Alcohol-related diseases of the oesophagus and stomach. Best Practice & Research Clinical Gastroenterol 2003; 17(4):557-73. 27. Pique N, Ponce M, Garrigues V, Rodrigo L, Calvo F, et al. Prevalence of severe esophagitis in Spain. Results of the PRESS study (Prevalence and Risk factors for Esophagitis in Spain: A crosssectional study). United Eur Gastroenterol J 2016; 4(2):229-35. 28. Bode C, Christian Bode J. Effect of alcohol consumption on the gut. Best Practice & Research Clin Gastroenterol 2003; 17(4):575-92. 29. Samokhvalov AV, Rehm J, Roerecke M. Alcohol consumption as a risk factor for acute and chronic pancreatitis: A systematic review and a series of meta-analyses. EBioMedicine 2015; 2(12):1996-2002. 30. Simet SM, Sisson JH. Alcohol’s effects on lung health and immunity. Alcohol Res 2015; 37(2):199-208. 31. Topiwala A, Allan CL, Valkanova V, Zsoldos E, Filippini N, et al. Moderate alcohol consumption as risk factor for adverse brain out comes and cognitive decline: longitudinal cohort study. BMJ 2017; 357:j2353 http://dx.doi.org/10.1136/bmj.j2353

14. Bell S, Daskalopoulou M, Rapsomaniki E, George J, Britton A, et al. Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records. BMJ 2017; 356:j909 https://dx.doi.org/10.1136/bmj.j909.

32. Hatchard T, Smith AM, Halchuk RE, Longo CA, Fried PA, et al. Effects of low-level alcohol use on cognitive interference: An fMRI study in young adults. Alcohol 2015; 49(1):7-13.

15. Taylor B, Irving HM, Baliunas D, Roerecke M, Patra J, et al. Alcohol and hypertension: gender differences in dose–response relationships determined through systematic review and metaanalysis. Addiction 2009; 104(12):1981–90. 16. Burton R, Henn C, Lavoie D, O’Connor R, Perkins C, et al. The public health burden of alcohol and the effectiveness and costeffectiveness of alcohol control policies: An evidence review. London: Public Health England, 2016.

33. Mellion ML, Silbermann E, Gilchrist JM, Machan JT, Leggio L, et al. Small-fiber degeneration in alcohol-related peripheral neuropathy. Alcohol Clin Exp Res 2014; 38(7):1965-72. 34. Syed S, Lioutas V. Tobacco-alcohol amblyopia: a diagnostic dilemma. J Neurol Sci 2013;327(1-2):41-45. 35. De la Monte SM, Kril JJ. Human alcohol-related neuropathology. Acta Neuropathol 2014;127(1):71-90. 36. Maurel DB, Boisseau N, Benhamou CL, Jaffre C. Alcohol and bone: review of dose effects and mechanisms. Osteoporos Int 2012;23(1):1-16.

17. Collart F, de Timary P, Dom G, Dor BD, Duprez D, et al. Alcoholinduced hypertension: an important healthcare target in Belgium. Acta Clin Belg 2015; 70(6):389-95.

37. Fernandez-Sola J, Preedy VR, Lang CH, Gonzalez-Reimers E, Arno M, Lin JC, et al. Molecular and cellular events in alcohol-induced muscle disease. Alcohol Clin Exp Res 2007;31(12):1953-62.

18. Ettinger PO, Wu CF, De La Cruz C, Weisse AB, Ahmed SS, et al. Arrhythmias and the “holiday heart” alcohol-associated cardiac rhythm disorders. Am Heart J 1978; 99:555-62.

38. Baliunas DO, Taylor BJ, Irving H, Roerecke M, Patra J, et al. Alcohol as a risk factor for type 2 diabetes: A systematic review and metaanalysis. Diabetes Care 2009; 32:2123–32.

GASTROENTEROLOGY TODAY - SUMMER 2018

13. Matsumoto C, Miedema MD, Ofman P, Gaziano JM, Sesso HD. An expanding knowledge of the mechanisms and effects of alcohol consumption on cardiovascular disease. J Cardiopulm Rehabil Prev 2014; 34(3):159-71.

FEATURE 39. Knott C, Bell S, Britton A. Alcohol consumption and the risk of type 2 diabetes: A systematic review and dose-response meta-analysis of more than 1.9 million individuals from 38 observational studies. Diabetes Care 2015; 38(9):1804–12.

48. Taylor B, Irving HM, Kanteres F, Room R, Borges G, et al. The more you drink, the harder you fall: a systematic review and meta-analysis of how acute alcohol consumption and injury or collision risk increase together. Drug and alcohol dependence 2010; 110(1):108-16.

40. Munukutla S, Pan G, Deshpande M, Thandavarayan RA, Krishnamurthy P, et al. Alcohol toxicity in diabetes and its complications: A double trouble? Alcohol Clin Exp Res 2016; 40(4):686-97.

49. Boden JM, Fergusson DM. Alcohol and depression. Addiction 2011; 106 (5):906–14.

41. Ballard HS. The hematological complications of alcoholism. Alcohol Health Res World 1997;21(1):42-52. 42. Schaeffner E, Ritz E. Alcohol and kidney damage: a Janus-faced relationship. Kidney Int 2012; 81(9):816-18. 43. Parisi R, Webb RT, Carr MJ, Moriarty KJ, Kleyn E, et al. Alcohol-Related Mortality in Patients With Psoriasis: A Population-Based Cohort Study. .JAMA Dermatol. doi:10.1001/ jamadermatol.2017.3225 Published online September 15, 2017. 44. Szabo G, Saha B. Alcohol’s effect on host defense. Alcohol Research: Current Reviews 2015; 37(2):159-70. 45. Jensen, TK., Hjollund, NH, Henriksen, TB, Scheike T, Kolstad H, et al. Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy. BMJ 1998; 317 (7157):505-10. 46. La Vignera S, Condorelli RA, Balercia G, Vicari E, Calogero AE. Does alcohol have any effect on male reproductive function? A review of literature. Asian J Androl 2013; 15(2):221-25. 47. Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, et al. Alcohol consumption and site-specific cancer risk: a comprehensive dose– response meta-analysis. Br J Cancer 2015; 112(3):580-93.

GASTROENTEROLOGY TODAY - SUMMER 2018

50. Farren CK, Hill KP, Weiss RD. Bipolar disorder and alcohol use disorder: a review. Curr Psych Rep 2012; 14(6):659–66. 51. Darvishi N, Farhadi M, Haghtalab T, Poorolajal J. Alcohol-related risk of suicidal ideation, suicide attempt, and completed suicide: A meta-analysis. PLoS ONE 2015; 10(5):e0126870. 52. Slade T, Chapman C, Swift W, Keyes K, Tonks Z, et al. Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression. BMJ Open 2016; 6:e011827.doi:10.1136/bmjopen-2016-011827. 53. Hart CL, Davey Smith G, Gruer L, Watt GC. The combined effect of smoking tobacco and drinking alcohol on cause-specific mortality: a 30 year cohort study. BMC Public Health 2010; 10:789. 54. Williams R, Aspinall R, Bellis M, Camps-Walsh G, Cramp M, et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet 2014; 384(9958):1953-97. 55. British Society of Gastroenterology and Bolton NHS Foundation Trust. Alcohol Care Teams: reducing acute hospital admissions and improving quality of care. London: NICE, 2016. Available online at https://arms.evidence.nhs.uk/resources/qipp/29420/attachment [accessed 18 January 2018].

FEATURE

SOMETHING FISHY GOING ON Amal Thomas, Alexander Zargaran, Andrew Poullis, St George’s Hospital, London A 33 year old chief stewardess on a luxury yacht presented with a 7

are neural, cardiac and gastro-intestinal tissues. Ciguatoxin leads to an

month history right upper quadrant pain which was constantly present

exaggerated parasympathetic tone and impaired sympathetic reflexes(5).

but with sharp exacerbations. The pain was cramp like and associated with bloating. There were no triggering or relieving factors. Over-the-

Ciguatoxin has also been shown to be transmitted sexually with a case

counter indigestion remedies and a trial of PPI therapy had no impact.

of a male affected suffering from painful ejaculation and his partner

The bloating tended to progress throughout the day and had no dietary

suffering from dyspareunia(6).

triggers. There was no change in bowel habit. Ciguatoxin poisoning is a clinical diagnosis. Symptoms start 15mins to One month prior to the onset of these symptoms was an episode of

a day after consumption of affected fish. Symptoms can be grouped

ciguatera poisoning following a meal while at sea. This manifest itself

into three categories according to the system affected. Gastrointestinal

predominantly with hyperaesthesia but also some mild gastrointestinal upset.

symptoms are first to appear and include diarrhoea, vomiting, nausea,

Several members of the crew had the same meal and similar symptoms. The patient recovered well from this but the gastrointestinal symptoms did not fully resolve before the new onset of these on-going pain and bloating.

painful defaecation and abdominal pain(5). Neurological symptom can vary from paraesthesia’s of the extremities to pain, arthralgia, myalgia, vertigo, paradoxical temperature sensation reversal and at the extreme

Remaining history was unremarkable. Physical examination was normal. Comprehensive investigations (standard haematology and biochemistry, abdominal and pelvic ultrasound, MRCP, small bowel MRI and OGD) were all normal.

end respiratory paralysis and coma(5). Cardiovascular symptoms arise from the exaggerated parasympathetic tone leading to bradycardia, hypotension and pulmonary oedema(5). Creatinine phosphokinase and lactate dehydrogenase may be elevated due to tissue breakdown. Management is largely supportive and addresses symptoms. Mannitol

A diagnosis of post-infective irritable bowel syndrome secondary to the episode of ciguatera poisoning was made. Due to on-going symptoms Citalopram 10mg once per day was started and after 8 weeks all symptoms had fully resolved and at follow up the patient remained well.

can be used to help reduce toxin levels(5). Activated charcoal can be given as with many ingested toxins. Drugs such as Gabapentin, Amitriptyline, NSAIDs and Antihistamines can be given to address symptoms (7). Most people usually make a full recovery after Ciguatoxin poisoning. Studies show patients usually make a full neuropsychological recovery in six months(8). Cardiovascular symptoms usually improve faster. Ciguatoxin

Ciguatera poisoning

can pass through the placenta and mothers milk and cause complications of pregnancy as well as spontaneous abortion. The mortality rate is

Ciguatera is a foodborne illness caused by the consumption of reef fish that have been contaminated with ciguatoxin. Ciguatoxin is a toxin produced by certain varieties of marine plankton known as dinoflagellates. In particular one variety of dinoflagellate, Gambierdiscus toxicus, has been shown to commonly cause Ciguatera(1). Ciguatera poisoning is the

reported to be 0.1% due to cardiovascular depression, respiratory paralysis or hypovolemic shock(9). Morbidity has been shown to be higher in children. Neurological symptoms, such as chronic pain and paraesthesia, have been shown to be present for a prolonged time in some individuals.

most common reported marine food-borne illness worldwide(2).

consumed by fish. These fish in turn are consumed by larger fish leading to biomagnification and increase in concentration of ciguatoxin in these fish(3). In particular, fish inhabiting coral reeds and warm waters are affected. An

Post infective irritable bowel syndrome (PI-IBS) is a well-recognised sequalae of gastroenteric infections. The mechanisms of PI-IBS are

affected fish may show no obvious sign of contamination but can become

not well understood (10). It is though that up to 4 – 32% of patients who

pale, weakened and display yellow eyes. Ciguatoxin is not removed from the

suffer from bacterial gastroenteritis go on to develop PI-IBS(11). Episodes

fish during the cooking progress and is also odourless and tasteless

of PI- IBS have been documented after infections with Campylobacter,

. This

(1,4)

means that it is not picked up by people involved in processing the fish nor

Salmonella, E. Coli and Shigella(11). However, there are no recorded

the person consuming the fish. Fish larger than two kilogrammes can have

instances of ciguatera poisoning leading to PI-IBS.

significant quantities of the toxin and produce a toxic effect when ingested. PI-IBS presents with much the same symptoms as those of IBS. The Ciguatoxin activates the voltage-dependent sodium channels at

diagnosis follows the Rome III criteria and symptoms must occur after

neuromuscular junction, this leads to hyperexcitability, spontaneous

a bout of gastroenteritis(11). The symptoms of gastroenteritis such as

repetitive neurotransmitter release, blockages of synaptic transmission

fever, vomiting and diarrhoea must be present prior to the onset of IBS

and depletion of synaptic vesicles. The tissue most commonly affected

symptoms such as abdominal discomfort, bloating and diarrhoea.

GASTROENTEROLOGY TODAY - SUMMER 2018

Post infective irritable bowel syndrome

These dinoflagellates can adhere to algae and seaweed that are

FEATURE It has also been suggested that PI-IBS differs from IBS in its symptoms

Campàs M et al. Identification of ciguatoxins in a shark involved in a

by showing more diarrhoeal features(12).

fatal food poisoning in the Indian Ocean. Scientific Reports. 2017;7(1). 4. Schep L, Slaughter R, Temple W, Beasley D. Ciguatera poisoning: an

Although the pathophysiology of IBS is not well understood, it is though

increasing occurrence in New Zealand. The New Zealand Medical

that factors such the duration and severity of the initial gastroenteritis can

Journal. 2010;123(1308):100-102.

increase the risk of PI-IBS following. Other factors that can contribute include the virulence of the pathogen, younger age and female sex(10). There is no treatment for PI-IBS that is specific to the condition. Management is largely the same as that of IBS, focussing on a symptom based approach. A follow up study of both IBS and PI-IBS patients over six years found that less than half had made a full recovery(11). It also found that having a history of anxiety and depression can impair recovery . A comparison (11)

5. Friedman M. Ciguatera Fish Poisoning: Treatment, Prevention and Management. Marine Drugs. 2008;6(3):456-479. 6. Robert Lange W, Michael Lipkin K, Yang G. Can ciguatera be a sexually transmitted disease?. Journal of Toxicology: Clinical Toxicology. 1989;27(3):193-197. 7. Calvert G, Hryhorczuk D, Leikin J. Treatment of Ciguatera Fish Poisoning with Amitriptyline and Nifedipine. Journal of Toxicology: Clinical Toxicology. 1987;25(5):423-428.

of recovery rates of those who had IBS prior to an infection and those

8. FRIEDMAN M, ARENA P, LEVIN B, FLEMING L, FERNANDEZ M,

whose IBS occurred after/due to an infection, found that there was no

WEISMAN R et al. Neuropsychological study of ciguatera fish

difference in the prognosis of either(11).

poisoning: A longitudinal case-control study. Archives of Clinical Neuropsychology. 2007;22(4):545-553. 9. Bagnis R, Laugier S, Kuberski T. Clinical Observations on 3,009 Cases

References

of Ciguatera (Fish Poisoning) in the South Pacific . The American Journal of Tropical Medicine and Hygiene. 1979;28(6):1067-1073.

1. Barton E, Tanner P, Turchen S, Tunget C, Manoguerra A, Clark R. Ciguatera fish poisoning. A southern California epidemic. Western journal of medicine. 1995;163(1):31-35. 2. Radke E, Reich A, Morris J. Epidemiology of Ciguatera in Florida. The American Journal of Tropical Medicine and Hygiene. 2015;93(2):425-432. 3. Diogène J, Reverté L, Rambla-Alegre M, del Río V, de la Iglesia P,

10. Sindrome dell’Intestino Irritabile Post-infettivo. La Clinica Terapeutica. 2011;162(2). 11. Ericsson C, Hatz C, DuPont A. Post infectious Irritable Bowel Syndrome. Clinical Infectious Diseases. 2008;46(4):594-599. 12. Neal K. Prognosis in post-infective irritable bowel syndrome: a six year follow up study. Gut. 2002;51(3):410-413.

e Health Manageme Diagnostics for Digestive Health Management Meet the experts at BSG on stand no. A158 Liverpool, ACC, 4-7th June

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OCTASA 400mg Modified Release Tablets (mesalazine) and OCTASA 800mg Modified Release Tablets (mesalazine) - Prescribing Information Presentation: Modified Release tablets containing 400mg mesalazine or 800mg mesalazine. Indications: Ulcerative Colitis - Treatment of mild to moderate acute exacerbations. Maintenance of remission. Crohn’s ileocolitis - Maintenance of remission. Dosage and administration: 400mg tablets – Adults: Mild acute disease: 6 tablets (2.4g) once daily or in divided doses, with concomitant steroid therapy where indicated. Moderate acute disease: 6 to 12 tablets (2.4g – 4.8g) daily. 2.4g may be taken once daily or in divided doses, higher doses should be taken in divided doses. Maintenance therapy: 3 to 6 tablets (1.2g – 2.4g) once daily or in divided doses. 800mg tablets - Adults: Mild acute disease: 3 tablets (2.4g) once daily or in divided doses with concomitant steroid therapy where indicated. Moderate acute disease: 3 to 6 tablets (2.4g – 4.8g) daily. 2.4g may be taken once daily, higher doses should be taken in divided doses. Maintenance therapy: 2 to 3 tablets (1.6g - 2.4g) once daily or in divided doses. 400mg and 800mg tablets – No more than 2.4g should be taken at one time. Tablets must be swallowed whole. Elderly: Normal adult dose may be used unless liver or renal function is severely impaired. Children: Limited documentation of efficacy in children >6 years old. Dose to be determined individually. Generally recommended that half the adult dose may be given to children up to a body weight of 40 kg; and the normal adult dose to those above 40 kg. Contra-indications: Hypersensitivity to salicylates, mesalazine or any of the excipients, severe impairment of hepatic or renal function (GFR less than 30 ml/min). Warnings and Precautions: Urinary status (dip sticks) should be determined prior to and during treatment, at discretion of treating physician. Caution in patients with raised serum creatinine or proteinuria. Stop treatment immediately if renal impairment is evident. Haematological investigations are recommended prior to and during treatment, at discretion of treating physician. Stop treatment immediately if blood dyscrasias are suspected or evident. Caution in patients with impaired hepatic function. Liver function should be determined prior to and during treatment, at the discretion of the treating physician. Do not use in patients with previous mesalazineinduced cardiac hypersensitivity and use caution in patients with previous myo- or pericarditis of allergic background. Monitor patients with pulmonary disease, in particular asthma, very carefully. In patients with a history of adverse drug reactions to sulphasalazine, discontinue immediately if acute intolerance reactions occur (e.g. abdominal cramps, acute abdominal pain, fever, severe headache and rash). Use with caution in patients with gastric or duodenal ulcers. Intact tablets in the stool may be largely empty shells. If this occurs repeatedly patients should consult their physician. Use with caution in the elderly subject to patients having normal or nonseverely impaired renal and liver function. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption, should not take this medicine. Interactions: No interaction studies have been performed. May decrease the anticoagulant activity of warfarin. May increase the myelosuppressive effects of azathioprine, 6-mercaptopurine or thioguanine. Monitoring of blood cell counts is recommended if these are used concomitantly. Fertility, pregnancy and lactation: Only to be used during pregnancy and lactation when the potential benefit outweighs the possible risk. No effects on fertility have been observed. Adverse reactions: Common: dyspepsia, rash. Uncommon: eosinophilia (as part of an allergic reaction), paraesthesia, urticaria, pruritus, pyrexia, chest pain. Rare: headache, dizziness, myocarditis, pericarditis, abdominal pain, diarrhoea, flatulence, nausea, vomiting, photosensitivity. Very rare: altered blood counts (aplastic anemia, granulocytosis, pancytopenia, neutropenia, leucopenia, thrombocytopenia), hypersensitivity reactions (such as allergic exanthema, drug fever, lupus erythematosus syndrome, pancolitis), peripheral neuropathy, allergic and fibrotic lung reactions (including dyspnoea, cough, bronchospasm, alveolitis, pulmonary eosinophilia, lung infiltration, pneumonitis), interstitial pneumonia, eosinophilic pneumonia, lung disorder, acute pancreatitis, changes in liver function parameters (increase in transaminases and cholestasis parameters), hepatitis, cholestatic hepatitis, alopecia, myalgia, arthralgia, impairment of renal function including acute and chronic interstitial nephritis and renal insufficiency, renal failure which may be reversible on withdrawal, nephrotic syndrome, oligospermia (reversible). Not known: pleurisy, lupus-like syndrome with pericarditis and pleuropericarditis as prominent symptoms as well as rash and arthralgia, intolerance to mesalazine with C-reactive protein increased and/or exacerbation of symptoms of underlying disease, blood creatinine increased, weight decreased, creatinine clearance decreased, amylase increased, red blood cell sedimentation rate increased, lipase increased, BUN increased. Consult the Summary of Product Characteristics in relation to other adverse reactions. Marketing Authorisation Numbers, Package Quantities and basic NHS price: 400mg - PL36633/0002; packs of 90 tablets (£16.58) and 120 tablets (£22.10). 800mg - PL36633/0001; packs of 90 tablets (£40.38) and 180 tablets (£80.75). Legal category: POM. Marketing Authorisation Holder: Tillotts Pharma UK Ltd, The Larbourne Suite, The Stables, Wellingore Hall, Wellingore, Lincolnshire, LN5 0HX, UK. Octasa is a trademark. ©2010 Tillotts Pharma UK Ltd. Further Information is available from the Marketing Authorisation Holder. Date of preparation of API: November 2017

For mild to moderate ulcerative colitis

* Using the same daily maintenance dose of 2.4g/day for a year. † Rounded down to the nearest whole patient. There are no clinical comparisons of Octasa® 400mg and 800mg vs Asacol® 400mg and 800mg. SmPCs may differ; consult individual SmPCs before prescribing.

ADVERTORIAL

Assuring Quality & Safety Of ‘Insourced’ Endoscopy Services Ten years ago, the phrase ‘increased demand for endoscopy services’

would mean the NHS service would lose its accreditation. This was a

was a repetitive refrain across most acute sector services as they

clear policy statement from the JAG that spoke directly to the need

struggled to cope with the realisation that we are living longer and

to ensure that quality and safety of patients was not compromised

therefore require more cancer screening services. Fast forward to

because of outsourcing.

2018 and the phrase has undoubtedly become the anthem for many services which are currently described as ‘just about coping’1 . Perhaps

Let us be very clear about the difference between a capacity solution

an equally ubiquitous phrase is that of ‘managed endoscopy services’

and capacity planning. The latter certainly requires a service to have

or ‘insourcing’ as it is more aptly described. Insourcing describes the

a strategy for demand management, better resource utilisation and

ever-popular solution being used across the NHS to try and provide

planning for future capacity requirements3. A capacity solution such

extra clinical capacity to match increasing demands. Essentially,

as insourcing, outsourcing or the use of mobile endoscopy units offers

trusts keep capacity planning projects in-house by collaborating with

a short to medium term solution to a difficult situation. The difficult

a provider of clinical services to ensure patients can be seen within

situation being unmanageable and mounting waiting lists. Despite

the trust. The obvious benefits of doing this being increased visibility

the short-term nature of these solutions, NHS services should resist

of the patient pathway and greater resilience of local services. There

any temptation to be influenced only by financial considerations

has been much ink spilt over the last few years about the virtues of

during procurement exercises and should also insist that they be of

insourcing, however, sadly, not much has been said about assuring

demonstrably good quality.

the quality of these managed services. As such, there is now a wide chasm between the market leaders of insourcing and the plethora of recruitment agencies that purport to be providers of managed clinical activity. In view of this disparity between providers, there is now a need for NHS services to reassure themselves that there is robust governance underpinning the provision of these services. The obvious solution to this situation is regulation of the sector. Understandably, this very important function necessarily falls to the Joint Advisory Group on GI Endoscopy JAG. The (JAG) accreditation standards were created to inspire the confidence of all stakeholders within endoscopy services- the patient, GASTROENTEROLOGY TODAY - SUMMER 2018

“Insourcing is a relatively new but rapidly progressing development for many NHS trusts. Balancing the need to achieve and maintain an excellent standard of clinical care whilst meeting waiting list targets and adhering to procurement guidance and regulations can present a formidable challenge. The new insourcing framework currently being developed by NHS Shared Business Service aims to help address this, by providing instant access to services without the need to procure locally for each occurrence, plus the reassurance of contracting under an agreed set of terms and conditions to ensure governance and quality assurance standards.” Caroline Wright , NHS Shared Business Services

endoscopy professionals, provider organisations and those who

Reassuringly, the JAG has already began consultations with insourcing

commission endoscopy services. These standards are now deeply

providers with a view to developing national standards for insourcing.

embedded into current endoscopy culture as can be evidenced by

These consultations are at a very early stages of development and

the record number of participating services (596 to be exact, across

much of the detail is currently left to speculation. Will accreditation

the acute and non-acute sector)2 submitting the annual GRS return.

be voluntary or compulsory? Which of the current acute sector

Perhaps unsurprisingly, the challenges services face in managing

standards will apply and in what manner? It could plausibly be

demand and the popular capacity solutions have always been

argued that the ‘clinical quality’ and ‘quality of the patient experience’

in the purview of the JAG. A few years ago, it issued a very timely

standards should apply to insourcing organisations as rigorously

statement which addressed ‘outsourcing’, then the most popular

as they do acute hospitals. Such a move would be welcomed by Dr

capacity solution. The message was clear - if the NHS service was JAG

Zach Tsiamoulos4 who is a prominent proponent of clinical quality in

accredited, it could only outsource clinical services to independent

endoscopy and has first-hand experience of monitoring the quality of

services which were themselves JAG accredited. To do otherwise

insourced services. While we impatiently await the JAG’s insourcing

1. Endoscopy in 2017: a national survey of practice in the UK, http://fg.bmj.com/content/flgastro/early/2018/04/28/flgastro-2018-100970.full.pdf?ijkey=29mR5rVeBJp3yzJ&keytype=ref 2. Joint Advisory Group on GI Endoscopy, www.thejag.org.uk 3. Endoscopy in 2017: a national survey of practice in the UK, http://fg.bmj.com/content/flgastro/early/2018/04/28/flgastro-2018-100970.full.pdf?ijkey=29mR5rVeBJp3yzJ&keytype=ref 4. Consultant Gastroenterologist and Clinical Lead for Endoscopy at East Kent Hospitals University NHS FT

ADVERTORIAL

Researched and written by Nicola Ellis-Webb Head of Clinical Services 18 Week Support

Did you know Over 100,000 endoscopy procedures were carried out through insourcing last year?

standards, it falls on individual NHS services who collaborate with insourcing providers, to have measures in place to quality assure these services themselves. Indeed, many services already have key performance indicators which requires insourced services to be clinically effective, safe for patients and provide a positive patient experience. Dr Matthew Banks5, believes that ensuring the highest quality of care and safety for patients should be at the heart of insourced services. He believes this is achieved by having robust

Indicators of Strong Governance • • • • • •

Excellent incident reporting culture Provision of feedback to staff involved in incidents Sharing of learning across the organisation Practical initiatives to protect patient safety Clinical leads engaged in review of quality metrics Evidence of Key Performance Indicators – Unplanned Readmissions, Day case to Inpatient, Surgical Site Infections, Mortalities, Returns to theatre Excellent JAG performance data from provider’s clinicians An assurance that clinicians are subject to an annual appraisal Evidence that the organisation actively monitors patient feedback and acts on findings Evidence that the organisation monitors staff feedback Evidence of good corporate governance and confirmation that the organisations are compliant with HMRC rules pertaining to the Intermediaries Legislation Evidence of strong Information Governance and compliance with GDPR rules.

systems and reporting structures as well as data capture and analysis processes to continually audit services. He went on to say that ‘insourced services must be responsive, transparent and there must be strong lines of communication between clinical leads from both organisations’. Vanessa Fernandis6 lends her voice as an expert in Governance & Risk

• • • • •

to the discourse. She believes that Integrated Governance processes should be evident at every level of the insourcing organisation, from

•

the board to the clinical staff. She added that ‘Data and the visibility of this, is imperative in helping healthcare organisations understand performance whether it is safety, quality and or efficiency. Key Performance Indicators (KPIs) help organisations understand how they are performing in relation to their strategic goals and objectives; it provides the most important information and acts as a dashboard to stakeholders highlighting whether the organisation is operating within

Equally, the following red flags are persuasive indicators that the organisation in question lacks strong governance. Red flag indicators

acceptable parameters’. Vanessa would like to see trusts insisting on

• Lack / weak clinical leadership

strong governance and accountability frameworks from insourcing

• Lack of a clearly defined audit framework

providers and believes that this can be achieved by requesting

• Provision of staff model with weak governance oversight

evidence of the following:

• Poor Corporate governance

Conclusion The demand for endoscopy services continues to grow and is expected to increase by 40% by 20207. While a strategy for long term capacity planning evolves through work undertaken by the professional bodies and NHS England, short and medium-term solutions are required. Insourcing is, by experience, the preferred option in many trusts to address demand. Provision of these service however, cannot be at a cost of compromised quality and safety. As such, it is imperative that until clear guidance and standards are published, organisations providing insourcing services, must have a robust structure. At the heart of this is clinical and organisational leadership, clear lines of communication and transparent reporting systems.

5. Consultant Gastroenterologist at UCLH, Secretary of BSGE, Clinical Lead for Endoscopy at 18 Week Support. 6. Head of Governance &Risk, 18 Week Support. 7. Brown et al. (2015), SCOPING THE FUTURE. An evaluation of endoscopy capacity across the NHS in England.

GASTROENTEROLOGY TODAY - SUMMER 2018

• Lack of emphasis on incident reporting and organisational learning

FEATURE

SIBO AND PROBIOTICS â&#x20AC;&#x201C; FIGHTING FIRE WITH FIRE? By Dr Malwina Naghibi, Medical Scientific Liaison, Protexin, Somerset, UK. www.protexin.com Is small intestinal bacterial overgrowth (SIBO) simply a trendy diagnosis or is it genuinely a rising problem amongst patients presenting in gastroenterology clinics? Nonstandardised diagnostic criteria combined with non-specific clinical manifestations make it difficult to assess the true prevalence of SIBO1,2. Depending on test and criteria, SIBO prevalence ranges from 1% to 21% in otherwise healthy populations, and from 23% to 78% in patients with irritable bowel syndrome1. Challenges around definition and diagnosis of SIBO have prevented the National Institute for Health and Care Excellence (NICE) from publishing treatment guidelines for patients with SIBO. As the underlying cause of SIBO is excessive amount of bacteria, antibiotics (especially broad spectrum) are often prescribed as first line treatment. Due to the close relationship between antibiotic resistance and antibiotic misuse, especially treatment discontinuation due to side effects, probiotics were suggested as an adjunct. This concept has worked in other conditions and has been shown to effectively reduce risk of antibiotic associated diarrhoea in both kids and adults, but is providing more bacteria

First line treatment and alternatives

to the overloaded intestine a safe and beneficial approach? The

In most cases, patients with suspected SIBO are offered a course of

growing evidence is supportive.

antibiotics. Rifaximin (poorly absorbed broad spectrum antibiotic), has been frequently studied3 and other antibiotics have also been explored

Healthy gut naturally defends against SIBO

GASTROENTEROLOGY TODAY - SUMMER 2018

with small trials on norfloxacin, co-amoxiclav, metronidazole and colistin suggesting positive results. However, whilst use of antibiotics provides reduction of the CFU in the small intestine, it results in reduction of

To understand how this could work, we need to consider how a

both pathogenic bacteria, along with normal commensal and beneficial

healthy gut is protected from SIBO. The human gastrointestinal

bacteria. Therefore, it was suggested that use of broad spectrum

tract is heavily colonised with bacteria, but type and abundance

antibiotics should be assisted by reintroduction of healthy bacteria.

of bacteria changes by distance to the oral cavity. Proximal small

Since Lactobacillus bacteria are commonly found in the small intestine,

bowel of healthy individuals is colonised with gram-positive aerobic

supplementation with probiotics containing strains of this genera

bacteria usually not exceeding 10 colony forming units (CFU)/

could confer benefit to the patients. Beneficial bacteria supplements,

ml, while the colon is full of strict anaerobes in amounts exceeding

known as probiotics, have been studied as alternative or adjunct

10 CFU/ml. A simplified healthy gut model would normally be

treatment for SIBO in several prospective randomised controlled trials.

colonised with Lactobacillus and Streptococcus (duodenum,

A meta-analysis published in 2017 showed significantly better SIBO

jejunum and proximal ileum), then with Clostridium, Streptococcus

decontamination rate (by 53%) in probiotics compared to placebo4.

and Bacteroides (distal ileum) and Clostridium, Bacteroides and

Significant improvement was seen in hydrogen breath tests and

Bifidobacterium in the colon. This is kept in check by complex

abdominal pain scores, but not in daily stool frequency.

systems including: 1) gastric juice and bile reducing pH in the proximal small intestine; 2) gut motility preventing adherence

This effect appears a little lower than decontamination rate seen with

of bacteria to the intestinal mucosa; 3) physical separation

rifaximin (average decontamination rate of 70%)3. However, rifaximin

between small and large intestine with ileocecal valve; 4) mucin

followed by a course of probiotics increased the success rate to

layer inhibiting pathogens; 5) antibacterial peptides (defensins) produced by epithelial cell lining1,2. When this complex system fails,

83%, and was related to no adverse events4,5. This is an important

small intestine becomes colonised with much higher numbers of

7% adverse event rate3. This comparison has certain limitations, as it

bacteria, often pathogens and bacteria normally seen in the colon.

compares a systematic review of multiple rifaximin studies with a single

observation, since a systematic review of rifaximin alone showed 2 â&#x20AC;&#x201C;

FEATURE

Optimising maintenance therapy for ulcerative colitis:

Real choices

When mesalazine doesn’t seem to be working, stepping up to immunosuppressants isn’t the only option

Real solution

Salofalk Granules are easy to take, they have a pleasant vanilla flavour, and they’re a proven way to help patients get the most from their mesalazine1-3

Optimising therapy with once-daily Salofalk Granules in patients who were inadequately maintained on previous mesalazine resulted in:2

69%

fewer days off work

45%

fewer GP visits due to UC

fewer steroid courses used

with impaired hepatic function. Should not be used in patients with impaired renal function. Mesalazine-induced renal toxicity should be considered if renal function deteriorates during treatment. Patients with pulmonary disease, in particular asthma, should be very carefully monitored. Patients with a history of adverse drug reactions to preparations containing sulphasalazine should be kept under close medical surveillance on commencement of treatment. Should Salofalk cause acute intolerance reactions such as abdominal cramps, acute abdominal pain, fever, severe headache and rash, therapy should be discontinued immediately. For patients with phenylketonuria – Salofalk granules contain aspartame as a sweetening agent equivalent to 0.56mg phenylalanine (500mg granules), 1.12mg phenylalanine (1000mg granules), 1.68mg phenylalanine (1.5g granules) and 3.36mg phenylalanine (3g granules). Salofalk granules contain sucrose: 0.02mg (500mg granules), 0.04mg (1000mg granules), 0.06mg (1.5g granules) and 0.12mg (3g granules). Interactions: Specific interaction studies have not been performed. Lactulose or similar preparations that lower stool pH: possible reduction of mesalazine release from granules due to decreased pH caused by bacterial metabolism of lactulose. In patients who are concomitantly treated with azathioprine, 6-mercaptopurine or thioguanine a possible increase in the myelosuppressive effects of azathioprine, 6-mercaptopurine or thioguanine should be taken into account. There is weak evidence that mesalazine might decrease the anticoagulant effect of warfarin. Use in pregnancy and lactation: There are no adequate data. Do not use during pregnancy unless the potential benefit outweighs the possible risks. Limited experience in the lactation period. Use during breast-feeding only if the potential benefit outweighs the possible risks; if the infant develops diarrhoea, breastfeeding should be discontinued. Undesirable effects: Headache, dizziness, peri- and myocarditis, abdominal pain, diarrhoea, flatulence, nausea, vomiting, aplastic anaemia, agranulocytosis, pancytopenia, neutropenia, leukopenia, thrombocytopenia, peripheral neuropathy, allergic and fibrotic lung reactions (including dyspnoea, cough, bronchospasm, alveolitis, pulmonary eosinophilia, lung infiltration, pneumonitis), acute pancreatitis, impairment of renal function including acute and chronic interstitial nephritis and renal insufficiency,

Mesalazine, the Dr Falk way GASTROENTEROLOGY TODAY - SUMMER 2018

Prescribing Information (Please refer to full SPC before prescribing): Salofalk gastro-resistant prolonged-release granules Presentation: Stick-formed or round, greyish white gastro-resistant prolongedrelease granules in sachets containing 500mg, 1000mg, 1.5g or 3g mesalazine per sachet. Indications: Treatment of acute episodes and the maintenance of remission of ulcerative colitis. Dosage: Adults: Once daily 1 sachet of 3g granules, 1 or 2 sachets of 1.5g granules or 3 sachets of 1000mg or 500mg granules (equivalent to 1.5-3.0g mesalazine daily) preferably to be taken in the morning, according to the individual clinical requirement. It is also possible to take the prescribed daily dose in three divided doses (1 sachet of 500mg granules three times daily or 1 sachet of 1000mg granules three times daily) if this is more convenient. Maintenance: 0.5g mesalazine three times daily (in the morning, at midday and in the evening) corresponding to a total dose of 1.5g mesalazine per day. For patients known to be at increased risk for relapse for medical reasons or due to difficulties to adhere to application of three daily doses the dosing schedule can be adapted to 3.0g mesalazine given as a single daily dose, preferably in the morning. Children: There is only limited documentation for an effect in children (age 6-18 years). Children 6 years of age and older: Active disease: To be determined individually, starting with 30-50mg/ kg/day once daily preferably in the morning or in divided doses. Maximum dose: 75mg/kg/day. The total dose should not exceed the maximum adult dose. Maintenance treatment: To be determined individually, starting with 15-30mg/ kg/day in divided doses. The total dose should not exceed the recommended adult dose. It is generally recommended that half the adult dose may be given to children up to a body weight of 40kg; and the normal adult dose to those above 40kg. Method of administration: The granules should be taken on the tongue and swallowed, without chewing, with plenty of liquid. Contra-indications: Hypersensitivity to salicylates or any of the excipients. Severe impairment of renal or hepatic function. Warnings/Precautions: Blood tests (differential blood count; liver function parameters such as ALT or AST; serum creatinine) and urinary status (dip sticks) should be determined prior to and during treatment at the discretion of the treating physician. Caution is recommended in patients

50%

photosensitivity especially with pre-existing skin conditions, alopecia, myalgia, arthralgia, hypersensitivity reactions such as allergic exanthema, drug fever, lupus erythematosus syndrome, pancolitis, changes in hepatic function parameters, hepatitis, cholestatic hepatitis and oligospermia (reversible). Legal category: POM. Basic cost: Salofalk 500mg granules, pack size 100 sachets – £28.74; 33.06€. Salofalk 1000mg granules, pack size 50 sachets – £28.74; 33.54€. Salofalk 1.5g Granules, pack size 60 sachets – £48.85; 52.22€. Salofalk 3g Granules pack size 60 sachets – £97.70; 108.98€ (UK – NHS price; IE – PtW). Product licence number: Salofalk 500mg granules – PL08637/0007; PA573/3/1. Salofalk 1000mg granules – PL08637/0008; PA573/3/2. Salofalk 1.5g granules PL08637/0016; PA573/3/7. Salofalk 3g granules PL08637/0025; PA573/3/6. Product licence holder: Dr Falk Pharma GmbH, Leinenweberstr.5, D-79108 Freiburg, Germany. Date of preparation: January 2018. Further information is available on request.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ (UK residents) or athttps:// www.hpra.ie/homepage/about-us/report-an-issue/human-adversereaction-form (residents of the Republic of Ireland). Adverse events should also be reported to Dr Falk Pharma UK Ltd.

References: 1. Salofalk Granules. Summary of Product Characteristics. 2. Aldulaimi D et al. Poster DRF16/057 presented at the BSG Annual Meeting, June 2016, Liverpool UK. 3. Keil R et al. Scand J Gastroenterol 2018; 21: 1-7. UC: ulcerative colitis Date of preparation: April 2018

DrF 18/095

FEATURE Furthermore, natural antimicrobial proteins like defensins are normally

Effectiveness of most antibiotic treatments in SIBO was increased to over 85% when used with probiotics as adjunct treatment. Probiotics alone showed higher effectiveness than metronidazole alone.

stimulated by Lactobacillus and Bifidobacteria and distributed in intestinal Paneth cells9. When the small intestine is colonised with different bacteria, this process could be altered, leading to insufficient or different defensins release.

What next? Emerging evidence suggests benefits from using probiotics in SIBO, but formulation of the most beneficial products requires further research, with dose, bacteria strains and product composition (single or multistrain products) considerations. There is a need for more evidence, before this could be translated into guidelines and implemented by NICE and other bodies, but current evidence suggests that combination of a broad spectrum antibiotic with multistrain probiotics appears to achieve the highest success rates from most reviewed interventions. To learn more about the use of probiotics in the treatment of SIBO and

trial of rifaximin and probiotics, but certainly offers an interesting avenue for future research. Analysis of two studies using either probiotics or metronidazole, pooled data showed that probiotics had 49% higher decontamination rate than seen with metronidazole4. Best results were seen when probiotics were used alongside antibiotics, reaching 86% decontamination rate4.

other conditions, please visit http://www.bio-kult.com/research or contact medical@protexin.com References 1. Ghoshal UC, Shukla R, Ghoshal U. Small intestinal bacterial overgrowth and irritable bowel syndrome: A bridge between functional organic dichotomy. Gut Liver. 2017;11(2):196-208. doi:10.5009/gnl16126.

Probiotics and SIBO â&#x20AC;&#x201C; what is the mechanism behind it?

2. Adike A, DiBaise JK. Small Intestinal Bacterial Overgrowth: Nutritional Implications, Diagnosis, and Management. Gastroenterol Clin North Am. 2018;47(1):193-208. doi:10.1016/j.gtc.2017.09.008.

How may supplementing bacteria to an environment overloaded with bacteria help? Firstly, probiotics are different to bacteria found in excessive amounts in the small intestine. To use a metaphor, SIBO is like a football team made up of 11 strikers, while introducing probiotics represents bringing goal keeper, defence and midfield players onto the pitch too. Because the effect of a bacteria is strain specific , probiotics 6

3. Gatta L, Scarpignato C. Systematic review with meta-analysis: rifaximin is effective and safe for the treatment of small intestine bacterial overgrowth. Aliment Pharmacol Ther. 2017;45(5):604-616. doi:10.1111/apt.13928. 4. Zhong C, Qu C, Wang B, Liang S, Zeng B. Probiotics for

containing multiple strains appear better able to stimulate the wide-

Preventing and Treating Small Intestinal Bacterial Overgrowth.

ranging defensive pathways protecting against SIBO.

J Clin Gastroenterol. 2017;51(4):300-311. doi:10.1097/ MCG.0000000000000814.

Normal gut microbiota stimulates MUC2 and MUC3 pathways controlling production of mucin7. Reduced abundance of healthy GASTROENTEROLOGY TODAY - SUMMER 2018

microbiota results in reduced mucus layer production, which can lead to increased adherence of bacteria to small intestine. In addition, if bacteria that colonise small intestine include colonic bacteria like Methanobrevibacter smithii (prolific methane producer), this can lead to reduced motility . 8

5. Cuoco L, Salvagnini M. Small intestine bacterial overgrowth in irritable bowel syndrome: a retrospective study with rifaximin. Minerva Gastroenterol Dietol. 2006;52(1):89-95. 6. Ouwehand AC, Salminen S, Isolauri E. Probiotics: An overview of beneficial effects. Antonie van Leeuwenhoek, Int J Gen Mol Microbiol. 2002;82(1-4):279-289. doi:10.1023/A:1020620607611. 7. Kim YS, Ho SB. Intestinal goblet cells and mucins in health and disease: Recent insights and progress. Curr Gastroenterol Rep. 2010;12(5):319-330. doi:10.1007/s11894-010-0131-2. 8. Triantafyllou K, Chang C, Pimentel M. Methanogens, methane and gastrointestinal motility. J Neurogastroenterol Motil. 2014;20(1):3140. doi:10.5056/jnm.2014.20.1.31. 9. SĂĄnchez B, Urdaci MC, Margolles A. Extracellular proteins secreted by probiotic bacteria as mediators of effects that promote mucosabacteria interactions. Microbiology. 2010;156(11):3232-3242. doi:10.1099/mic.0.044057-0.

FEATURE

PATIENT EMPOWERMENT (PE) IN IRRITABLE BOWEL SYNDROME (IBS) By Dr MP Eugenicos, MD, PhD, FHEA, Senior Lecturer & Gastroenterologist at Western General Hospital Gastroenterology Department, University of Edinburgh & Medical Adviser to The IBS Network charity.

Introduction

Materials & Methods

Patient Empowerment (PE) has become very popular – encouraging

30 consecutive patients (F:M ratio=4:1; age-range: 18-70 years,

patients to take an active role in the management of their own health.

mean:47)) attending the Specialist Motility clinic in Edinburgh were

This concept is assisting the development of quality health systems1.

recruited and completed a questionnaire (Table 1).

PE is regarded as a priority by patients and healthcare organisations2. It is not clear, however, how PE can be successfully delivered3; different technological approaches are utilised with no unified opinion on this1.

Results

Irritable Bowel Syndrome, or IBS, is characterised by chronic abdominal

The majority of patients wished to receive further education about their

pain and altered bowel habit in the absence of any organic cause4 with

condition. Only 30% of patients received relevant information prior to

a pathophysiology which is multifactorial based on gut-brain interaction5.

attending the Specialist clinic; this however, was regarded as helpful.

It is a common condition and, as such, leads to a considerable

60% of patients expressed the need for further information regarding

healthcare burden6. A recent audit, to review the clinical practice in

symptoms and their management (Figure 1a). 57% of patients preferred

Scotland, showed lack of adherence to the NICE guidelines in IBS and

information in the form of an educational leaflet (EL). In addition to EL,

highlighted the need for education and expansion of resources available

patients (30%) requested interactive approaches such as workshops

in primary care to optimise patients’ management7. IBS severity of

and/or an ‘App’ (Figure 1b). The EL was considered by patients to be

symptoms improved in patients engaged in a self-help bibliotherapy

an effective way to receiving and retaining information. There was no

ACT (Acceptance-Commitment-Therapy), but with no impact on quality

correlation between the duration of symptoms and patient’s knowledge.

of life8; quality of life however was predicted by psychological flexibility and acceptance9. Thus, do self-help PE approaches address patients’

Furthermore, 87% of patients considered the previous education helpful

requirements? Our recent study at the University of Edinburgh aimed to

in understanding their symptoms (Figure 2a), whereas 37% of patients

assess the IBS-patients’ educational needs.

did not find it useful in the management of their symptoms (Figure 2b).

GASTROENTEROLOGY TODAY - SUMMER 2018

FEATURE

•

Figure 2a. Has previous information helped you understand your condition?

•

Figure 2b. Has previous information helped you manage your symptoms? 16

16 12

GASTROENTEROLOGY TODAY - SUMMER 2018

8 6

4 4

FEATURE

GASTROENTEROLOGY TODAY - SUMMER 2018

FEATURE • Figure 3. Patients’ comments of what is important to include in a leaflet (Pathophysiology of symptoms in the centre of their choices) BTM: Beverley Travis Mixture

Patients were asked to observe their preferences in an EL. By popular

such as IBS. Evaluating PE may influence not only the future of medical

demand, patients requested a section on pathophysiology of IBS

care but the effectiveness and advancement of research on this

symptoms and lifestyle advice (Figure 3).

concept1.

Discussion

References

PE in chronic conditions includes five dimensions: ‘identity’, ‘knowledge-

1. Calvillo J, Román I, and Roa LM. 2015. How technology is empowering patients? A literature review. Health Expect;18(5):643–652. 2. Greig E, and Williams M. 2015. Improving evidence-based management of IBS across Somerset. [online: https://www.nice.org.uk/sharedlearning/improvingevidence-based-management-of-irritable-bowel-syndrome-across-somerset Accessed: 03/05/18@15:30] 3. Small N, Bower P, et al. 2013. Patient empowerment in long-term conditions: development and preliminary testing of a new measure. BMC Health Serv Res.;8(13):263. 4. Drossman DA. 2016. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical features and Rome IV. Gastroenterology;150:1262–79. 5. Eugenicos MP, Syme PD and Moore D. 2015. The clinical significance of sensory abnormalities in Irritable Bowel Syndrome. Gut;64:141-142 6. Yannakou Y, Eugenicos MP, et al. 2015. Economic and quality-of-life burden of moderate-to-severe Irritable Bowel Syndrome with Constipation (IBS-C) in the UK: The IBIS-C study. Gut;64(1):33-34 7. Moroni F, Eugenicos MP. 2017. Scottish Gut Motility disorder Clinic: Review of Activity Over 1 year Period. Presented @. 25th UEGW, Barcelona. 8. Gillanders d, Eugenicos MP, et al. 2017. An implementation trial of ACT-based bibliotherapy for IBS. J of Cont Behav Science;6(2):172-177 9. Ferreira NB, Eugenicos MP, et al. 2013. Measuring acceptance in IBS: preliminary validation of an adapted scale and construct utility. Qual Life Res.;22(7):1761-1766 10. Cerezo PG, Juvé-Udina ME, Delgado-Hito P. 2016. Concepts and measures of patient empowerment: a comprehensive review. Rev Esc Enferm USP;50(4):667–74.

and-understanding’, ‘personal-control’, ‘personal-decision-making’, and ‘enabling-other-patients’3. The aforementioned data showed that patients ask for EL in line with ‘identity’, and ‘knowledge-andunderstanding’. The need to understand the pathophysiology of GASTROENTEROLOGY TODAY - SUMMER 2018

symptoms is consistent with ‘personal-control’ – “If I know what triggers my symptoms then I may control them”. Patients were keen for information on lifestyle advice in keeping with ‘personal-decisionmaking’. The request for workshops demonstrates the PE fifth dimension of ‘enabling-other-patients’. Comparable to other chronic conditions, there is a need for PE in IBS; patients are eager to enrich their health education. In partnership with patients and Primary Care, we should aim to produce a more comprehensive patient-directed view of empowerment. The above study enlightened us of what the approach could be. Such EL will require subsequent validation that involves patient-reported outcome measure assessment. PE strategies positively impact on healthcare outcomes; are likely to shape the future of medical practice10 and in particular chronic illnesses

NEWS New £750k fund opens for research in gluten free food production and coeliac disease diagnostics and self-care Coeliac UK, the UK charity for people who need to live gluten free, along with Innovate UK, the UK’s innovation agency is today, Monday 14 May 2018, open for applications from businesses and researchers to the £750,000 fund. Researchers and businesses can apply for a share of the funding through three priority themes – healthcare diagnostics, digital self-care tools and better gluten free food production – with the grants ranging from £50k to £250k. For more information see www.coeliac.org.uk/innovateuk . Earlier in the year, as part of the charity’s 50th Anniversary activities, Coeliac UK launched a Research Fund and accompanying fundraising appeal, aiming to raise £5 million to change the future for people with coeliac disease and gluten related autoimmune conditions. More information see: www.coeliac.org.uk/ researchfund.

The Fund has already received an injection of £500k from Innovate UK which in addition to £250k from the charity, will support this new research competition. Together with match funding from industry total spend on new research for a growing global market will be nearer £1m. Sarah Sleet, chief executive of Coeliac UK said: “With the global diagnosis for coeliac disease increasing year on year, this is a chance for UK business and researchers to get ahead and develop competitive advantages in innovation which will be of benefit to a badly underserved patient group. We are thrilled to be working with Innovate UK to promote innovation that will have a real and positive impact on people’s lives.” Calum Murray, head of agriculture and food at Innovate UK, said: “By funding great new ideas which will help diagnose and care for people with coeliac disease and by encouraging tasty new developments in gluten free food, this competition promises to make a real difference. Not just for those living with coeliac disease but it will help fuel innovation in our food and health sectors – crucial components of the government’s industrial strategy. This competition is a first for Innovate UK in how we have teamed up with the leading charity Coeliac UK to boost the funding

available for fantastic new proposals from industry and academia.’’ The three priority themes: Coeliac disease diagnostics New methods of diagnosis which are less invasive, or that are accurate without eating gluten could improve diagnosis rates and lead to early effective treatment, in turn leading to better quality of life and reduced risk of complications for patients with the condition. Enhanced quality of gluten free foods Creating more nutritious and affordable gluten free food could include; novel ingredients, foods with improved nutrient profiles and desired flavour texture characteristics, new methods of preservation, innovation in processing and manufacturing efficiency for lower cost options and technologies to improve shelf life. Digitally supported self-care Coeliac disease is a serious autoimmune condition which requires lifelong management. Self-care using digital tools could provide a highly cost effective option for health management. Find out more about this competition and to apply: www.coeliac.org.uk/innovateuk

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GASTROENTEROLOGY TODAY - SUMMER 2018

DeepBlueTM Polyp Lifting Solution

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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.

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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)

GASTROENTEROLOGY TODAY - SUMMER 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. 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: March 2018 Company reference: UK/PLV/0318/0059

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 2018; 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.

PLENVU, MOVIPREP, NORGINE and the sail logo are registered trademarks of the Norgine group of companies. UK/PLV/0418/0081 Date of preparation: May 2018.

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 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

NEWS Crohn’s and Colitis UK launches a new resource to increase the number of specialist nurses working in Inflammatory Bowel Disease Specialist Inflammatory Bowel Disease (IBD)[1] Nurses provide invaluable support and expertise to improve patients’ quality of life and give them more control over their treatment. However, one in three people with Crohn’s Disease or Ulcerative Colitis do not have access to a specialist nurse[2]. Crohn’s and Colitis UK[3] have created a new web resource[4] to encourage more general nurses to specialise in IBD and to support existing IBD nurse specialists,as they believe that everyone living with IBD in the UK should have access to an IBD Nurse Specialist. Following recent reports that thousands of nurses are leaving the profession each year[1], it has never been more important to encourage nurses to stay in the profession and specialise. Crohn’s and Colitis UK’s new resource gives nurses the tools, support and encouragement for a clear defined career pathway and service development. The website hosts advice and information on becoming an IBD Nurse Specialist, information for those wanting to explore options for building an IBD team for their trust, an IBD nurse map, and a nurses hub to get connected with other IBD Nurses. At least 300,000 people in the UK live with Crohn’s Disease or Ulcerative Colitis - and the numbers affected are rising. Often diagnosed younger in age, these conditions are lifelong, relapsing and remitting and cost the NHS over £900 million per year. Lifetime medical costs associated with IBD care are comparable to diabetes or cancer. National audits demonstrate that patients with IBD experience variable care across UK. Nurse specialists empower patients by helping them understand their condition, support self-management and shared decision-making and deliver responsive, patient-centred care. Patients often describe their IBD Nurse Specialist service as a lifeline. Easy access to the IBD Nurse Specialist at times of relapse, and to help support self-management is central to responsive, sustainable, quality care and good clinical outcomes. Without an IBD Nurse Specialist, evidence shows that patients are more likely to require emergency intervention, or fall out of specialist services. Although the number of IBD Nurse Specialists across the UK is increasing, only 2% of IBD Nursing teams meet the minimum number of nurses recommended per 250,000 population. 63% of IBD

Nurse Specialists report a higher caseload than recommended levels (500 patients per full time nurse) and caseloads of up to 2000 patients have been reported. Consequently, services are often suspended in the nurse’s absence, nurses are contributing significant unpaid overtime to meet demand, and patients are not receiving the high quality service that IBD Nurses can deliver. Isobel Mason, Service Development IBD Nurses at Crohn’s and Colitis UK said; “The availability of IBD nurse specialists across the UK is vital for people living with IBD to be able to access responsive health services and improved clinical outcome. Specialist IBD nurses play a fundamental role in delivering high quality patient care and experience, lead patient centred service redesign, improve the quality of care and represent excellent value for money. I think this new resource will benefit so many healthcare professionals and help to improve the quality of care for all of those with IBD.”

Coeliac UK launch research fund to change the future for people with coeliac disease and gluten related autoimmune conditions Coeliac UK, the largest independent charity for people who need to live gluten free, this week launches a research fund and accompanying fundraising appeal, aiming to raise £5 million to change the future for people with coeliac disease and gluten related autoimmune conditions. The research appeal is being headed up by Coeliac UK’s patron, actor Caroline Quentin who was diagnosed with the autoimmune disease three years ago. It will boost research efforts into key areas identified and agreed by patients, carers and healthcare professionals. The full list can be found at: www.coeliac.org.uk/researchfund. With the charity celebrating its 50th anniversary this year, there is a greater urgency to find better answers to the disease, which has links to other autoimmune conditions such as Type 1 diabetes and autoimmune thyroid disease and still relies on the gluten free diet as its only treatment. Sarah Sleet, chief executive of Coeliac UK said: “It is possible through further research, that finding the answers to coeliac disease could enable answers to other devastating autoimmune conditions such as Type 1 diabetes. With more people being diagnosed with coeliac disease each year and with new health complications emerging, it is critical that we make the commitment now to change the status quo and make coeliac disease research everyone’s priority.”

GASTROENTEROLOGY TODAY - SUMMER 2018

Moviprep and Moviprep Orange (Macrogol 3350, sodium sulphate, ascorbic acid, sodium ascorbate and electrolytes) 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: March 2018. Ref UK/MPR/0318/0182

NEWS A video was produced as part of the appeal launch to show the impact of the disease on those affected and can be viewed on: www.coeliac.org.uk/researchfund. The video shows the various presentations of coeliac disease including refractory coeliac disease type 2 (which is not responsive to the gluten free diet), osteoporosis and gluten ataxia. The Fund has already received an injection of £500k from Innovate UK, the UK’s innovation agency, which in addition to £250k from the charity, will support a new research competition. Match funding will draw in a further £250k from industry making the first £1 million available from the Fund. Dr Ian Campbell, Director of Ageing Society, Health and Nutrition, Innovate UK said: “It’s fantastic to be working with charities such as Coeliac UK to promote innovations that will have a real, positive impact on people’s lives.” Coeliac UK has already committed over £2 million to research projects since 2005 including ground breaking discoveries such as identifying genes associated with coeliac disease and other autoimmune conditions related to gluten. And also funded research towards a vaccine to restore immune tolerance to gluten.

GASTROENTEROLOGY TODAY - SUMMER 2018

“50 years ago little was known about coeliac disease and the gluten free diet, bread used to come in a tin and people wrongly thought children would grow out of the autoimmune disease. Fast forward to today and both the disease and the diet are firmly on the worldwide map and 150,000 diagnosed people in the UK now live a better way of life thanks to improved recognition and diagnosis. However, half a million people remain undiagnosed and we need more support to help them get diagnosed and managing their condition with a gluten free diet. But, we also know that there needs to be a more permanent solution to this complex disease so we are boosting our research efforts and awareness raising as part of our 50th anniversary activities,” Ms Sleet said. Coeliac UK is the national charity for people who need to live without gluten, whether due to coeliac disease or another medical condition requiring a gluten free diet. Coeliac disease is a serious autoimmune condition caused by a reaction to gluten, a protein found in wheat, barley and rye. People diagnosed with coeliac disease must maintain a strict gluten free diet for the rest of their life if they are to avoid very serious complications such as osteoporosis, infertility and although rare, small bowel cancer.

Coeliac disease Despite improvements in coeliac disease diagnosis over the past 50 years, on average people will live with undiagnosed coeliac disease for 13 years before diagnosis, with some people suffering day to day with constant, debilitating symptoms such as diarrhoea, stomach pain and severe fatigue. If left undiagnosed and untreated, coeliac disease can lead to complications such as osteoporosis, infertility, irreversible neurological damage (ataxia, neuropathy) and in rare cases, small bowel lymphoma. Coeliac disease is a serious autoimmune condition caused by a reaction to gluten, a protein found in wheat, barley and rye. One in hundred people in the UK has the condition but around half a million people in the UK are currently undiagnosed. First degree relatives of someone diagnosed with coeliac disease increase their risk of having coeliac disease to one in ten. People present with a wide range of symptoms both gut and non-gut related ie frequent bouts of diarrhoea, constipation, nausea, vomiting, flatulence and bloating, mouth ulcers, anaemia, severe fatigue, repeated miscarriages and unexplained neurological problems. Many see coeliac disease as just a disease affecting the gut, when in fact it is a systemic disease that affects other parts of the body. Coeliac disease is often missed because the patient is not presenting with gut symptoms, but rather they may present with neurological symptoms and are directed to a neurologist rather than a gastroenterologist. In a study of patients with newly diagnosed coeliac disease, who had been referred to a gastroenterology clinic, around three out of five had established neurological symptoms including severe headache (45%), balance problems (26%) and sensory symptoms (14%). People are also misdiagnosed, with one in four people diagnosed with coeliac disease previously being treated for irritable bowel syndrome. The NICE guideline CG61, Irritable bowel syndrome (IBS) in adults: diagnosis and management (2008) identifies the need to rule out coeliac disease before making a diagnosis of IBS. It is important that patients have not removed gluten from their diet prior to testing, to prevent a false negative result. As a minimum, it is recommended that foods containing gluten

must have been included in more than one meal per day, every day for a minimum of six weeks, prior to serological testing. Important to note, in the cases of negative serology, if symptoms and history are suggestive of a diagnosis, the NICE guideline for recognition, assessment and management of coeliac disease NG20 (2015) suggests a referral should be made. Delayed diagnosis of coeliac disease is associated with development of neurological conditions such as gluten ataxia and gluten related neuropathy which can have lifelong debilitating impacts. The treatment of gluten related neurological conditions is – like coeliac disease – a lifelong strict gluten free diet. The longer the symptoms go untreated, the more likely there will be no or limited improvement in the condition. When there is gluten related neurological damage the gluten free diet can make a difference with improvements being related to earlier diagnosis. In its 50th Anniversary year, Coeliac UK is urging health professionals to take coeliac disease seriously. The charity launched a Research Fund in March this year to raise £5 million towards research into coeliac disease and other gluten related autoimmune conditions. As part of the launch, the charity has thrown more light on the association with neurological conditions, along with the more severe and life threatening form of the disease, refractory coeliac disease type II, which is rare and affects a very small proportion of the coeliac population. For more information and videos of case studies see: www.coeliac.org.uk/researchfund For your patients who are newly diagnosed with coeliac disease or another condition requiring a gluten free diet, Coeliac UK has all the tools they need to adapt to the diet and receive ongoing support. As the only UK charity for people needing to live gluten free, for as little as £2 a month, members get access to comprehensive food and drink product information, an extensive gluten free recipe database, as well as advice on where to eat out, food alerts and a food scanning app to make shopping easier. Patients can feel quite isolated and alone when first diagnosed so the charity provides access to a large and supportive gluten free community, including a strong local group network and member to member support service. For more information visit www.coeliac.org.uk

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Rapid access to high quality NHS commissioned endoscopy services in community gastroenterology clinics

NEWS Current Perspectives on Helicobacter Pylori Management Georgina L. Hold1*, Peter Malfertheiner2, Colm Oâ&#x20AC;&#x2122;Morain3 on behalf of the European Helicobacter and Microbiota Study Group & United European Gastroenterology Introduction H. pylori prevalence rates vary around the world with infection rates reaching 90% in some countries. H. pylori eradication offers the optimal interventional opportunity in gastric cancer prevention by eliminating the principal cause of disease. 90% of non-cardia gastric cancers can be attributed to the H. pylori infection (1). From the global perspective gastric cancer ranks third in malignancy related mortality. The expected median 5-year survival in the western world, where the disease most often is diagnosed only after the onset of alarm symptoms, is less than 30% (2, 3). The chance of survival in patients with gastric cancer is much better in East Asia due to implementation of strategies for gastric cancer prevention. Updates on H. pylori Surveillance Recent studies from Japan and Korea, reporting on gastric cancer screening programs, based on serology (pepsinogen I) and /or endoscopy found an increased detection rate of early gastric cancer and thus in a curable stage with significant reduction in mortality from the disease (4, 5). In a recent

prevention by H. pylori eradication is

substitution of Vonoprazan, a novel potassium-

well documented has successfully been

competitive acid blocker that provides reversible

demonstrated in 7 randomized clinical

acid suppression by preventing potassium from

trials and 8 cohort studies recently revisited

binding to gastric H+/K+-ATPase, for PPIs has

and analyzed in two metanalyses (9, 10).

shown promising results, however remains to be

Successful gastric cancer prevention by H.

tested outside Asia (19-22).

pylori eradication is now confirmed also in a Western population conducted in Sweden.

Quadruple therapy is gaining in popularity

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particularly in areas with increasing resistance

study of 95,176 patients who received H.

to standard triple therapy. Whether three

pylori eradication therapy the follow up after

antibiotics, or Bismuth and two antibiotics are

5 to 7.5 years showed a decreased risk of

used, excellent eradication rates are achieved,

gastric cancer below that expected in the

albeit with increased side-effects (23, 24).

corresponding background population (11).

Tailored, culture-based treatment seems a logical choice, and has significant success

A major uncertainty has always been whether

(25). However, there is an expense and delay

the time of intervention for H. pylori eradication

involved, which limits its universal use at

to prevent gastric cancer had not surpassed

present. Molecular based antibiotic resistance

the critical point of no return. At the stage of

can give a more rapid result. At the moment,

severe atrophic gastritis, even with no longer

antibiotic sensitivity is recommended prior to

persisting H. pylori infection, the risk for

proceeding with third line therapies (16).

progression to cancer is highest (12). In this context an important contribution has been

Levofloxacin remains the most favoured

made in a prospective randomized placebo-

second line therapy, however Bismuth, when

controlled trial conducted in Korea. Authors

available, is an increasingly successful option.

reported a 50% reduction in incidence of

Sequential therapy remains an option in areas

secondary (metachronous) gastric cancer

of high resistance but may prove challenging

in a 5-year follow-up by H. pylori eradication

in terms of compliance (26). Three-in-one

compared to placebo after the endoscopic

formulations may improve compliance (27, 28).

removal of early gastric cancer (13). A

Probiotics do not appear to have any direct

further striking finding in this study was the

effect on H. pylori activity, but their addition

demonstration of a significant reduction of

does improve eradication rates, which is likely

the gastric atrophy after successful H. pylori

due to improved compliance as a result of

eradication. Since a subset of patients will

reduced side effects (29).

have progression to gastric cancer, even after successful H. pylori eradication, surveillance

There have been many guidelines for H. pylori

endoscopy following endoscopic resection of

treatment published, which may lead to some

early gastric cancer should be continued at

confusion. However, most are in agreement

regular intervals.

with the most recent iteration of the Maastricht

study on a Finnish population of 329 gastric

GASTROENTEROLOGY TODAY - SUMMER 2018

treatment guidelines which recommends

cancer patients, pre-diagnostic low serum

In conclusion new data confirm and strengthen

14-day triple therapy in areas with low

pepsinogen I and anti-H. pylori antibodies

the important role of H. pylori eradication in

clarithromycin resistance, and bismuth-

were significantly associated with increased

gastric cancer prevention(15) and support the

based quadruple therapy in areas with high

gastric cancer risk (6, 7). Despite some

recommendation to adopt screen and treat

clarithromycin resistance (16). In addition, the

inherent limitations to serological screening,

strategies in regions with high gastric cancer risk

European Registry on H. pylori management,

the findings suggest the appropriateness in

but encourage such strategies also in regions

supported by the European Helicobacter

using such screening strategy also in Europe

with intermediate and low risk as well (16). One

and Microbiota Study Group (EHMSG) is an

to identify subjects at risk for gastric cancer

such strategy is the inclusion of screening for

exciting new endeavour which represents an

with subsequent options for personalized

premalignant gastric lesions in national colorectal

audit process to ensure clinical practice is

therapeutic management (8). Such options

gastric cancer screening (17).

aligned with best standards of care. There are

according to individual patient needs are

now over 21,000 entries from 27 European

either endoscopic resection of early neoplastic

Treatment

countries and promises to provide invaluable

gastric lesions, follow-up with endoscopic/

The treatment of H. pylori continues to evolve

information regarding H. pylori treatment

histologic monitoring in case of severe

(18). Triple therapy has been modified in that it is

across Europe.

atrophic gastritis, cure of H. pylori infection

now recommended to use double dose (80mg)

when present or a combination of them.

proton-pump inhibitor (PPI), quadruple dose

H. pylori Antibiotic Resistance

(2g) Amoxicillin and Clarithromycin (1g) for at

Antibiotic resistance rates to H. pylori infection

least 10 days, and preferably 14 days (16). The

are continuing to rise, with drug resistance

The effectiveness of primary gastric cancer

1 Department of Medicine, St George & Sutherland Clinical School, University of New South Wales, Sydney, NSW 2217, Australia. 2 Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Magdeburg, Magdeburg, Germany. 3 Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin D2, Ireland. * Correspondence to: Georgina Hold: email: georgina.hold@unsw.edu.au, phone: +61 (2) 9113 1855

NEWS rates varying based on the different treatment regimes. In February 2017, the WHO categorised H. pylori, in terms of antibioticresistance, as a high-priority. Despite several factors influencing efficacy of anti-H. pylori therapy, including duration of treatment, formulation and dose, resistance remains the most critical factor (16). The most recent study to look at resistance rates, published in 2015, indicates that primary resistance rates to clarithromycin, metronidazole and levofloxacin have significantly increased over the previous 15 years. Different reporting approaches across geographical locations makes it challenging to directly compares resistance rates however, there is a clear upwards trajectory (26). Sequential therapy has also shown to be effective when targeted against strains with single antimicrobial resistance with > 93% eradication rates which dropped to 83% when used against dual resistant strains. Whatever antibiotic regime is used, the reality is that all patients are receiving unnecessary courses of antibiotics as treatment is rarely based on H. pylori antibiotic susceptibility testing (30). There is a clear need for a new approach to H. pylori eradication which is

7. Song M, Camargo MC, Weinstein SJ, Murphy G, Freedman ND, Koshiol J, et al. Serum pepsinogen 1 and anti-Helicobacter pylori IgG antibodies as predictors of gastric cancer risk in Finnish males. Alimentary Pharmacology & Therapeutics. 2018;47(4):494-503. 8. Zagari RM, Rabitti S, Greenwood DC, Eusebi LH, Vestito A, Bazzoli F. Systematic review with meta-analysis: diagnostic performance of the combination of pepsinogen, gastrin-17 and antiHelicobacter pylori antibodies serum assays for the diagnosis of atrophic gastritis. Alimentary Pharmacology & Therapeutics. 2017;46(7):657-67. 9. Lee YC, Chiang TH, Chou CK, Tu YK, Liao WC, Wu MS, et al. Association Between Helicobacter pylori Eradication and Gastric Cancer Incidence: A Systematic Review and Meta-analysis. Gastroenterology. 2016;150(5):1113-24.e5.

11. Doorakkers E, Lagergren J, Engstrand L, Brusselaers N. Helicobacter pylori eradication treatment and the risk of gastric adenocarcinoma in a Western population. Gut. 2018. gutjnl-2017-315363. doi: 10.1136/gutjnl-2017-315363. 12. Rugge M, Meggio A, Pravadelli C, Barbareschi M, Fassan M, Gentilini M, et al. Gastritis staging in the endoscopic followup for the secondary prevention of gastric cancer: a 5-year prospective study of 1755 patients. Gut. 2018. gutjnl-2017-314600. doi: 10.1136/gutjnl-2017-314600. 13. Choi IJ, Kook MC, Kim YI, Cho SJ, Lee JY, Kim CG, et al. Helicobacter pylori Therapy for the Prevention of Metachronous Gastric Cancer. The New England Journal of Medicine. 2018;378(12):1085-95. 14. Cheung KS, Chan EW, Wong AYS, Chen L, Wong ICK, Leung WK. Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study. Gut. 2018;67(1):28-35.

10. Seta T, Takahashi Y, Noguchi Y, Shikata S, Sakai T, Sakai K, et al. Effectiveness of Helicobacter pylori eradication in the prevention of primary gastric cancer in 15. Malfertheiner P. Helicobacter pylori healthy asymptomatic people: A systematic Treatment for Gastric Cancer Prevention. review and meta-analysis comparing The New England Journal of Medicine. risk ratio with risk difference. PLoS One. 2017;12(8):e0183321. ScheBo_GastroToday_Jan_2017 2018;378(12):1154-6. 12/01/2017 17:18

informed by antibiotic susceptibility data which will allow antibiotic regimens to be selected based on evidence. References 1. Plummer M, Franceschi S, Vignat J, Forman D, de Martel C. Global burden of gastric cancer attributable to Helicobacter pylori. Int J Cancer. 2015;136(2):487-90. 2. Colquhoun A, Arnold M, Ferlay J, Goodman KJ, Forman D, Soerjomataram I. Global patterns of cardia and non-cardia gastric cancer incidence in 2012. Gut. 2015;64(12):1881-8.

4. Hamashima C, Shabana M, Okada K, Okamoto M, Osaki Y. Mortality reduction from gastric cancer by endoscopic and radiographic screening. Cancer Science. 2015;106(12):1744-9. 5. Jun JK, Choi KS, Lee HY, Suh M, Park B, Song SH, et al. Effectiveness of the Korean National Cancer Screening Program in Reducing Gastric Cancer Mortality. Gastroenterology. 2017;152(6):1319-28.e7. 6. Malfertheiner P. Editorial: the non-invasive diagnosis of atrophic gastritis. Alimentary Pharmacology & Therapeutics. 2017;46(1112):1112-3.

GASTROENTEROLOGY TODAY - SUMMER 2018

3. De Angelis R, Sant M, Coleman MP, Francisci S, Baili P, Pierannunzio D, et al. Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE-5-a population-based study. The Lancet Oncology. 2014;15(1):23-34.

NEWS 16. Malfertheiner P, Megraud F, O’Morain CA, Gisbert JP, Kuipers EJ, Axon AT, et al. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut. 2017;66(1):6-30. 17. Tepes B, Seruga M, Vujasinovic M, Urlep D, Ljepovic L, Brglez JN, et al. Premalignant Gastric Lesions in Patients Included in National Colorectal Cancer Screening. Radiology and Oncology. 2018;52(1):7-13. 18. O’Connor A, Lamarque D, Gisbert JP, O’Morain C. Treatment of Helicobacter pylori infection 2017. Helicobacter. 2017;22 Suppl 1. 19. Ozaki H, Harada S, Takeuchi T, Kawaguchi S, Takahashi Y, Kojima Y, et al. Vonoprazan, a Novel Potassium-Competitive Acid Blocker, Should Be Used for the Helicobacter pylori Eradication Therapy as First Choice: A Large Sample Study of Vonoprazan in Real World Compared with Our Randomized Control Trial Using Second-Generation Proton Pump Inhibitors for Helicobacter pylori Eradication Therapy. Digestion. 2018;97(3):212-8. 20. Yang X, Li Y, Sun Y, Zhang M, Guo C, Mirza IA, et al. Vonoprazan: A Novel and Potent Alternative in the Treatment of AcidRelated Diseases. Digestive Diseases and Sciences. 2018;63(2):302-11. 21. Sue S, Ogushi M, Arima I, Kuwashima H, Nakao S, Naito M, et al. Vonoprazan- vs proton-pump inhibitor-based first-line 7-day

GASTROENTEROLOGY TODAY - SUMMER 2018

triple therapy for clarithromycin-susceptible Helicobacter pylori: A multicenter, prospective, randomized trial. Helicobacter. 2018;23(2):e12456. 22. Tanabe H, Ando K, Sato K, Ito T, Goto M, Sato T, et al. Efficacy of Vonoprazan-Based Triple Therapy for Helicobacter pylori Eradication: A Multicenter Study and a Review of the Literature. Digestive Diseases and Sciences. 2017;62(11):3069-76. 23. Tursi A, Di Mario F, Franceschi M, De Bastiani R, Elisei W, Baldassarre G, et al. New bismuth-containing quadruple therapy in patients infected with Helicobacter pylori: A first Italian experience in clinical practice. Helicobacter. 2017;22(3). 24. Wang L, Lin Z, Chen S, Li J, Chen C, Huang Z, et al. Ten-day bismuth-containing quadruple therapy is effective as first-line therapy for Helicobacter pylori-related chronic gastritis: a prospective randomized study in China. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2017;23(6):391-5. 25. Cosme A, Montes M, Ibarra B, Tamayo E, Alonso H, Mendarte U, et al. Antimicrobial susceptibility testing before first-line treatment for Helicobacter pylori infection in patients with dual or triple antibiotic resistance. World Journal of Gastroenterology. 2017;23(18):3367-73.

26. Gatta L, Scarpignato C, Fiorini G, Belsey J, Saracino IM, Ricci C, et al. Impact of primary antibiotic resistance on the effectiveness of sequential therapy for Helicobacter pylori infection: lessons from a 5-year study on a large number of strains. Alimentary Pharmacology & Therapeutics. 2018;47(9):1261-9. 27. Miehlke S, Frederking D, Gunther T, Glocker E, Eisele B, Andresen V, et al. Efficacy of three-in-one capsule bismuth quadruple therapy for Helicobacter pylori eradication in clinical practice in a multinational patient population. Helicobacter. 2017;22(6). 28. Rodriguez de Santiago E, Martin de Argila de Prados C, Marcos Prieto HM, Jorge Turrion MA, Barreiro Alonso E, Flores de Miguel A, et al. Limited effectiveness with a 10-day bismuth-containing quadruple therapy (Pylera((R)) ) in third-line recue treatment for Helicobacter pylori infection. A real-life multicenter study. Helicobacter. 2017;22(5). 29. Si XB, Lan Y, Qiao L. A meta-analysis of randomized controlled trials of bismuthcontaining quadruple therapy combined with probiotic supplement for eradication of Helicobacter pylori. Zhonghua nei ke za zhi. 2017;56(10):752-9. 30. Dang BN, Graham DY. Helicobacter pylori infection and antibiotic resistance: a WHO high priority? Nature reviews Gastroenterology & Hepatology. 2017;14(7):383-4.

COMPANY NEWS

DELIVERING ENDOSCOPY THE MEDINET WAY by Dr Iqbal Khan, MB ChB, BSc, PhD FRCP, Consultant Gastroenterologist and Medical Advisor to Medinet Clinical Services Ltd.

Introduction There is unprecedented demand on endoscopy services across the UK and NHS Trusts are under tremendous pressure to achieve waiting list targets. These pressures are especially felt by their respective endoscopy units with potential to receive fines for missing targets and lose JAG accreditation. This usually happens when patients can expect to wait more than six weeks for endoscopy. Hence units have to increase their capacity but maintain their quality and positive patient experiences. This now has to be done in a time for austerity, where the NHS as a whole is expected to make 2% efficiency savings per year. (1)

The solution When Units have exhausted their capacity, workload can be outsourced or insourced. Outsourcing involves sending patients offsite to an external endoscopy provider. This is often a private hospital in the vicinity. It is important that JAG accredited units only outsource to other JAG accredited units (2). Insourcing involves bringing in experienced practitioners (endoscopists, nurses and decontamination staff) into the units own space to optimise its capacity. The overall control of this work, including quality monitoring remains under the scrutiny of the Endoscopy Unit and itâ&#x20AC;&#x2122;s governance structure.

Complaints and complications are extremely low. Recent audit data, which is being presented at the BSG annual meeting 2018, shows that over a 12 month period 25,347 endoscopic procedures were carried out and only17 complaints (0.07%) were received with 28 adverse incidents (0.11%).

Case study Medinet Clinical Services Ltd was asked to work with Royal Free London NHS Foundation Trust to see patients in gastroenterology clinics and to carry out endoscopic procedures to ensure the Trust was able to deliver a high quality services and hit their targets with timeliness.

Procedures Undertaken Colons

Gastros

Flexis

Total

5,776

5,596

1,346

12,718

In addition to endoscopy work, between June 2016 and January 2017, 1,589 patients were seen in the outpatient clinic by Medinet consultants. Great feedback was received for this work, both from the patients and the full-time staff within the Trust. In total, Medinet only received 5 complaints over this whole period. All of these were dealt with very quickly by the Medinet Clinical Governance team. In 2018, Royal Free London NHS Foundation Trust awarded Medinet a very competitive long term contract to deliver endoscopy and gastroenterology services.

Conclusions The last two decades have seen an incredible transformation in the delivery and quality of endoscopy services across the UK. However, with increasing demands and no significant increase in capacity or resources, there is a possibility that this work could be undone. The endoscopy community should use every opportunity to ensure that this does not happen. Insourcing of endoscopy services is one possible solution to the problem and one that ensures Trusts maximise their own capacity and aspire to deliver a 7-day service. It is fundamentally important that all insourcing activity is closely monitored to ensure clinical and information governance is in not compromised. Patient safety as well as satisfaction should always be core to the service provided. Medinet Clinical Services Ltd is a highly experienced provider of Clinical gastroenterology and endoscopy services. It should be the first choice for any Trust looking for a reliable and experienced partner to deliver additional capacity.

References 1. NHS. The five-year forward view. 2014. 2. JAG outsourcing Policy, www.thejag.org.uk, 2015.

GASTROENTEROLOGY TODAY - SUMMER 2018

Medinet have been delivering endoscopy insourcing to endoscopy units for nearly 10 years. Over this time approximately 175,000 endoscopic procedures were carried out all over the United Kingdom and now also the Republic of Ireland. Medinet is able to deliver a high quality service as their endoscopists are highly experienced consultants who hold substantive posts within the NHS and nurses are highly experienced specialised endoscopy nurses.

Endoscopy work started in July 2015 and was carried out by JAG accredited consultants in substantive NHS posts assisted by highly experienced endoscopy nurses. The table shows the total numbers of endoscopic procedures carried out (to the end of April 2018):

COMPANY NEWS

DIAGMED HEALTHCARE CONTINUED INNOVATION IN HEALTHCARE As one of the UK’s leading independent GI distributors we have always supported innovation and concept development within the healthcare industry. This year marks the launch of one of our most advanced projects in collaboration with the NHS. After several years of development, we are delighted to launch our DeepBlue™ Polyp Lifting solution based on years of research and the need for effective tools to ensure safe, easy and consistent resection capability. With the increase in EMR and polypectomy, generally the need to standardise treatments as well as remove risky pre-procedural preparation in line with NHS Guidelines on pre-mixed solutions has been met. The launch of this new product reinforces our strong existing portfolio of market leading and Gold standard products. Our recent launch of Pillcam™ Crohn’s expands the range of our Capsule Endoscopy platform into a whole new clinical environment, allowing physicians the broadest choice of non-invasive tests. Our bleed management portfolio has expanded with the addition of

the launch of the Roth Net® Select to create a range of grasping nets that are indication specific and are tailored to a wide variety of clinical challenges that other devices cannot adapt to. We are also launching our long awaited short wire biliary platform, FAST™, to allow short wire users access to a unique range of covered and uncovered biliary stents. Again, this addition helps to create one of the broadest portfolios of metal stents that can help physicians treat a wide range of clinical indications. After many years of successful promotion of the SPOT® Tattooing product we are delighted to bring to market a new and upgraded version, SPOT® Ex. Now CE approved for clinical surveillance as well as lesion localisation, the new product is clinically proven to support the need for post procedural observation to help speed up lesion localisation and minimise the risk of both missing lesions or surgical errors. Our aim for the coming years is to continue to deliver clinically valued

Purastat , Viper Haemostatic clips and Padlock Clips to create one

products in conjunction with our partners and the NHS as well as

of the most extensive portfolios for the treatment of post EMR, or

continuing to deliver training and support to end users to ensure optimal

perforation bleeding.

utilisation. We aim to enhance our existing training platforms to meet the

needs of all healthcare professionals to help promote best practice as Our unrivalled Roth Net® portfolio has been further enhanced with

GASTROENTEROLOGY TODAY - SUMMER 2018

well as deliver customer service excellence.

COMPANY NEWS

MID YORKSHIRE NHS TRUST EMBRACES ‘FIRST OF ITS KIND’ SOLUTION UK’s first mobile decontamination unit launches at Pinderfields Hospital Following the launch of the market’s first mobile endoscopy decontamination unit late last year, the Mid Yorkshire Hospitals NHS Trust is the first trust in the UK to bring the ground-breaking solution to their hospital estate.

responds directly to the reprocessing challenges hospitals are facing, solving a major gap in the endoscopy market. “We have to thank the team at Mid Yorkshire for their willingness to embrace innovation with the introduction of this unit. We hope they will

Partnering with leading mobile medical unit provider, EMS Healthcare,

be the first of many.”

Quest+ Decontamination has been introduced at Pinderfields Hospital in Wakefield to support endoscope reprocessing services while vital department refurbishment work takes place. The innovative new unit will ensure the hospital can continue services without disruption to the department or its patients – removing the need to use external decontamination services. The single trailer solution minimises the footprint required on site. Features include four RapidAER® Reprocessors, a double endoscopy grade sink, integral RO plant, a track and trace system and clean and dirty areas enabling a one-way flow for scopes. Angela Fairbank, Hospital Sterilisation and Decontamination Department (HSDU) Manager at Pinderfields Hospital, commented: “As a trust that promotes the use of research and innovation to solve healthcare challenges, we are extremely proud to be at the forefront of this new solution. Without the Quest+ Decontamination unit, we were facing a period of sustained disruption to services and patients. EMS Healthcare

The launch at Pinderfields Hospital also marks the start of EMS Healthcare’s official partnership with reprocessing equipment provider, Cantel (UK) Ltd, and RO plant provider, Veolia Water Technologies. The partnership means the Quest+ Decontamination unit can now offer healthcare providers a one-stop solution for their endoscopy reprocessing needs. Keith added: “Cantel and Veolia stand with us in our efforts to aid hospitals in the delivery of uncompromised care – providing a turnkey solution is a major part of this so it is with great pleasure we welcome them on board.” Neil Blewitt, Managing Director at Cantel, said: “Collaboration is the cornerstone of our equipment provision, and we’re proud to partner on a solution that will help to solve pressing equipment and capacity challenges.”

came to us with a solution that could not only prevent this from happening, but could create significant efficiencies for the department.”

Lorraine Gledhill, Business Development Manager at Veolia Water Technologies UK said: “We’re excited to be part of this first of its

Keith Austin, CEO at EMS Healthcare, added: “The onsite launch

kind solution for the endoscopy market. It’s the perfect solution

at Pinderfields Hospital is the culmination of a considered and

that supplements any Endoscopy department during their hospital

collaborative development process for Quest+ Decontamination. We

refurbishment phases – we’re looking forward to seeing more trusts

have worked closely with healthcare providers to create a solution that

embrace the offering around the UK.”

GASTROENTEROLOGY TODAY - SUMMER 2018

Helicobacter Test INFAI ® The most used 13C-urea breath test for the diagnosis of Hp-infection worldwide

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