Gastroenterology Today - Autumn 2018 by Media Publishing Company

Volume 28 No. 3

Autumn 2018

Gastroenterology Today Market Leaders in Reducing Endoscopy Waiting List Times in the NHS.

In this issue Gastrointestinal disorders: impact of the microbiota on autoimmune disease FIT negative follow up

think

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

CONTENTS

CONTENTS 5

EDITORS COMMENT

FEATURE G astrointestinal disorders: Impact of the microbiota on autoimmune disease

FEATURE F IT Negative Follow-Up

FEATURE B rain, Gut or Microbiome, Where should we target in Irritable Bowel Syndrome (IBS)?

NEWS

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

BSG POSTERS

COVER STORY The Endoscopy Group – Who We Are

Gastroenterology Today

Market Leaders in Reducing Endoscopy Waiting List Times in the NHS.

At The Endoscopy Group we believe that the only way to support NHS Trusts with cancer, urgent, routine and planned waiting times compliance is to provide the best team possible. All of the Consultants, Endoscopy Nurses and Decontamination Technicians we work with all hold a substantive position in an NHS Trust. Endoscopy plays an important role in the diagnosis and treatment of cancer and digestive diseases. The benefits are maximised when procedures are performed at the highest level of quality. Technical failures and adverse events are more likely to occur when procedures are performed by inexperienced endoscopists. At The Endoscopy Group we only recruit consultants who meet and exceed JAG standards. Our recruitment and compliance processes form the base of our vetting of all staff who work with us.

All contracts are supplied with a team which will remain mostly constant for the lifetime of the contract. This is to ensure the relationships which are built from the initial weekend are maintained and enhanced to ensure a quality service and excellent patient experience. For more information please contact Darren Simpkin, Operations Director on 0203 846 3333 or email Darren.simpkin@TheEndoscopyGroup.co.uk

Next Issue Spring 2019 Subscription Information – Autumn 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. UK: Other medical staff - £18.00 inc. postage Non-medical Individuals - £24.00 inc. postage Institutions Libraries Commercial Organisations - £48.00 inc. postage Rest of the World: Individuals - £48.00 inc. postage Institutions Libraries Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details. Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design

GASTROENTEROLOGY TODAY - AUTUMN 2018

Part of this includes the review of Consultant GRS data, in accordance with JAG guidance and our internal performance standards, which all Consultants must supply. We collate internal GRS data and performance KPIs for each Consultant, this is reviewed on a 6 monthly basis as part of our governance and quality assurance process.

PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company.

MULTI-STRAIN PROBIOTICS THAT COMPLEMENT THE , DOCTOR S ORDERS. SUPPORT AND HELP RESTORE PATIENTS GUT HOMEOSTASIS Probiotic strains with proven clinical efficacy in more than 10 published human trials. Bio-Kult is a scientifically developed, advanced multi-strain probiotic formula containing 14 live bacterial strains, from 5 different genera. Bio-Kult Infantis contains 7 live bacterial strains present in the early infant microbiota.

To find out more about Bio-Kult and how you can prescribe to your patients contact 01460 243 230 or info@bio-kult.com BNF: Bio-Kult_Cap (091104000BBNTA0)

EDITORS COMMENT

EDITORS COMMENT Enhanced screening in patients with IPMNs - a lesson to learn Whilst there is no debate about the malignant potential of intraductal papillary mucinous neoplasms (IPMNs) within the pancreas, there remains some confusion about their association with extra-pancreatic cancers. Early studies reported an association between IPMNs and extra-pancreatic cancers, but these included cancers that had been diagnosed before, or at the same time as, the IPMN. In the absence of clinical guidelines, some gastroenterologists would routinely carry out a panel of investigations, including invasive endoscopies, to exclude extra-pancreatic cancers in patients found to have an IPMN. This approach has the potential to expose patients to risks to both their physical and mental health, as well as burdening an already resource-constrained healthcare system. We must be convinced of any benefits before doing so. With the ageing population and advances in CT imaging, a growing number of patients are being diagnosed with IPMNs. Fortunately the evidence base grows with the prevalence of any condition. More recent, prospective studies have not found any increase in the incidence of extrapancreatic cancers during the follow up period after diagnosis of IPMN. It may be that the association of IPMN with historical cancers is simply a result of more frequent crosssectional imaging in this cohort. One of the posters included in this quarter’s issue of Gastroenterology Today adds to the evidence base debunking the notion that IPMNs are associated with an increased risk of extra-pancreatic cancers. The recent European guidelines are clear: there is insufficient evidence to support enhanced screening for extra-pancreatic cancers in patients with IPMNs. Hopefully this will give clinicians the confidence to refrain from over-investigating patients with this condition moving forwards. You can no doubt think of other examples of CT findings that prompt extensive investigation for occult malignancy, often in the absence of a strong evidence base - mesenteric panniculitis springs to mind. For conditions such as this, even small, single-centre studies could provide enough evidence to significantly alter clinical practice, and this should encourage fellow junior doctors to get involved in research.

Dr Ben Shandro Clinical Research Fellow St George’s Hospital

GASTROENTEROLOGY TODAY - AUTUMN 2018

“With the ageing population and advances in CT imaging, a growing number of patients are being diagnosed with IPMNs. Fortunately the evidence base grows with the prevalence of any condition.”

FEATURE

GASTROINTESTINAL DISORDERS: IMPACT OF THE MICROBIOTA ON AUTOIMMUNE DISEASE Dr Davinder Garcha, Medical Scientific Liaison, ADM Protexin Our immune system is essential to protect us against infection from pathogenic bacteria and viruses. Ironically, the maturation of the immune system is largely dependent on a collection of friendly (or commensal) bacteria found in the intestines, known as the gut microbiota. This microbiota is essential for a range of host physiological processes, including vitamin production and carbohydrate fermentation/digestion, and act as a physical barrier to pathogens that may attempt to infect us. For the immune system, the gut microbiota helps in the development of the gut-associated lymphoid tissue, where the majority of our immune cells reside. In addition, they also help the immune system to differentiate, providing tailored and appropriate responses to pathogens. A complex interaction between the immune system and the gut microbiota allow both to flourish. However, in some people this relationship may become compromised

Inflammatory bowel disease Complex in origin, inflammatory bowel disease (IBD) is associated with an abnormal highly inflammatory immune response to the host intestinal microbiota, resulting in damage to the GI tract. In the UK, approximately 620,000 people suffer from IBD, at a cost to the NHS in excess of £1 billion, and it also has a significant global burden (Table 1).7,8 In both Crohn’s disease and ulcerative colitis (UC), there is reduced gut microbiota diversity compared to healthy controls – specifically, a reduction in the Firmicutes phylum and an increase in the Proteobacteria phylum.9,10 There are a number of suggested mechanisms by which IBD symptoms may emerge, including (i) an imbalance between pro- and anti-inflammatory T-cell responses, (ii) altered epithelial barrier function and (iii) dysbiosis of the intestinal microbiota. The natural history of IBD includes bouts of relapse (flare-ups) and remission.

due to gut microbiota dysbiosis, defined as bacterial disturbance or imbalance in the gut including in the type and numbers of bacteria present.1 This dysbiosis can lead to infection taking hold, or in some cases, the development of autoimmune diseases.2 Autoimmune conditions including coeliac disease, Crohn’s disease, ulcerative colitis and autoimmune hepatitis have increased in prevalence in recent decades and are significant burdens not just on patients but also on healthcare systems in the developed world.

Coeliac disease GASTROENTEROLOGY TODAY - AUTUMN 2018

It is estimated that approximately 1% of people suffer from coeliac disease (CD) in western populations. Dysbiosis of the gut microbiota is commonly seen in CD patients.3 Initial treatment for CD is simply to switch to a gluten-free diet. However, a dysbiotic gut microbiota is associated with persistent GI symptoms in gluten-free CD patients.

Crohn’s annual incidence UC annual incidence

Europe

North America

Asia

12.7*

20.2*

0.54*

1.7-13.6*

7.6-19.5*

0.3-5.8*

Crohn’s peak age of onset

20-30 years (globally)

UC peak age of onset

30-40 years (globally)

Risk Factors for IBD

Environmental triggers (smoking, diet, stress); genetic susceptibility; abnormal immune interaction with microbiota; impaired immunity

Table 1. Epidemiology of inflammatory bowel disease globally.8 *Values are per 100,000 person-years. IBD = Inflammatory bowel disease, UC = ulcerative colitis.

Compared with healthy individuals, the coeliac microbiota has reduced levels of beneficial bacteria, particularly Lactobacillus and

Whether gut dysbiosis is a primary cause or secondary manifestation of

Bifidobacterium species, whereas it has higher levels of the pro-

IBD is an important question, and a 2016 animal model study investigated

inflammatory enteric gram-negative bacteria such as Shigella and E.

this further. Genetically susceptible germ-free mice (lacking the gene for

coli.

It has therefore been suggested that in addition to a gluten-free

anti-inflammatory IL-10, therefore more prone to IBD development) were

diet, correction of gut microbiota dysbiosis is an important component

inoculated with gut microbiota from either Crohn’s or UC patients, or

to help patients with CD. Lindfors and colleagues reported that probiotic

healthy controls. It was found that gut dysbiosis from IBD patients was

supplementation was associated with reduced gliadin-induced intestinal

replicated in the mice, and this was associated with increased expression

permeabilty (B. lactis) in an in vitro model, and Smecuol and colleagues

of pro-inflammatory gene expression compared with healthy controls.

showed that B. infantis was associated with a reduction in GI symptoms

Crohn’s disease microbiota exposure resulted in overt intestinal pathology

in CD patients who were not following any other treatment.5,6

in germ-free mice (not seen in healthy control-inoculated mice).

FEATURE Crohn’s disease

2. de Oliveira GLV, Leite AZ, Higuchi BS, Gonzaga MI, Mariano VS.

With Crohn’s costing the NHS an average of over £6,000 per patient

Intestinal dysbiosis and probiotic applications in autoimmune

per year7, there has been interest in investigating probiotics as a way

diseases. Immunology. 2017;152(1):1-12. doi:10.1111/imm.12765.

to correct the significant gut dysbiosis seen in Crohn’s disease and improve outcomes. However, a recent systematic review showed no benefit of probiotics in inducing remission of active disease, for the prevention of relapse of quiescent disease or for the prevention of relapse following surgical induction of remission.11

3. Cenit MC, Olivares M, Codoñer-Franch P, Sanz Y. Intestinal Microbiota and Celiac Disease: Cause, Consequence or CoEvolution? Nutrients. 2015;7(8):6900-6923. doi:10.3390/nu7085314. 4. Coqueiro AY, Bonvini A, Tirapegui J. Probiotics supplementation as an alternative method for celiac disease treatment. Int J Probiotics

Ulcerative colitis As with Crohn’s, there is no known cure for UC. However, although the evidence for probiotics in Crohn’s is lacking, there appears to be hope for UC. Due to the gut dysbiosis seen in UC, in addition to the ability of probiotics to improve intestinal barrier permeability and displace pathogens, use of probiotics to improve clinical outcomes has been explored in a number of trials.12 A systematic review from Shen and colleagues found that

Prebiotics. 2017;12(1):23-32. 5. Lindfors K, Blomqvist T, Juuti-Uusitalo K, et al. Live probiotic Bifidobacterium lactis bacteria inhibit the toxic effects induced by wheat gliadin in epithelial cell culture. Clin Exp Immunol. 2008;152(3):552-558. doi:10.1111/j.1365-2249.2008.03635.x. 6. Smecuol E, Hwang HJ, Sugai E, et al. Exploratory, Randomized,

probiotics significantly improved the remission rates in patients with active

Double-blind, Placebo-controlled Study on the Effects of

UC, compared with placebo (risk ratio = 1.51; P = 0.01).13

Bifidobacterium infantis Natren Life Start Strain Super Strain in Active Celiac Disease. J Clin Gastroenterol. 2013;47(2):139-147. doi:10.1097/MCG.0b013e31827759ac.

Autoimmune hepatitis

7. Ghosh N, Premchand P. A UK cost of care model for inflammatory bowel disease. Frontline Gastroenterol. 2015;6(3):169-174.

Autoimmune hepatitis (AIH) is a progressive liver disorder characterised by ongoing hepatocellular inflammation and necrosis, which may ultimately lead to liver cirrhosis. It has previously been documented that AIH is associated with an impaired intestinal barrier (leaky gut) and intestinal microbiome dysbiosis, and this may play a significant role in the pathogenesis of AIH. A recent study examined the role of the gut microbiota

doi:10.1136/flgastro-2014-100514. 8. Arora SS, Malik TA. Inflammatory Bowel Disease: Epidemiology. In: New Insights into Inflammatory Bowel Disease. InTech; 2016. doi:10.5772/64313. 9. Pascal V, Pozuelo M, Borruel N, et al. A microbial signature

in both a mouse model genetically susceptible to autoimmunity as well

for Crohn’s disease. Gut. 2017;66(5):813-822. doi:10.1136/

as via biopsies of autoimmune and healthy humans.14 In the mice, the

gutjnl-2016-313235.

gut pathobiont Enterococcus gallinarum translocated to systemic organs driving an autoimmune pathophysiology. This pathology was reversed by either vancomycin treatment or by vaccination against E. gallinarum. Fascinatingly, in human biopsies, E. gallinarum was seen at a significantly higher rate in AIH patients than in healthy controls. The corticosteroid

10. Matsuoka K, Kanai T. The gut microbiota and inflammatory bowel disease. Semin Immunopathol. 2015;37(1):47-55. doi:10.1007/ s00281-014-0454-4. 11. Derwa Y, Gracie DJ, Hamlin PJ, Ford AC. Systematic review with

prednisolone (with or without azathioprine) is currently the mainstay of

meta-analysis: the efficacy of probiotics in inflammatory bowel

treating AIH. It has been speculated that probiotics, as an adjunctive

disease. Aliment Pharmacol Ther. 2017;46(4):389-400. doi:10.1111/

therapy, may be of benefit in treating the condition, but no research has

apt.14203.

yet been published investigating this.15 Incidentally, the treatment of liver cirrhosis with probiotics has been shown to prevent the development of hepatic encephalopathy.16

microbiota is becoming clearer over time, and this association may

AW. Systematic review of randomized controlled trials of probiotics, prebiotics, and synbiotics in inflammatory bowel disease. Clin Exp Gastroenterol. 2014;7. doi:10.2147/CEG.S27530. 13. Shen J, Zuo Z-X, Mao A-P. Effect of Probiotics on Inducing

manifest in any of a range of different conditions. Probiotics have

Remission and Maintaining Therapy in Ulcerative Colitis, Crohn’s

shown considerable promise in a number of autoimmune conditions,

Disease, and Pouchitis. Inflamm Bowel Dis. 2014;20(1):21-35.

and further research will help determine the best use of probiotics in

doi:10.1097/01.MIB.0000437495.30052.be.

conjunction with standard therapies. For further information on this topic, please feel free to contact the Protexin Bio-Kult Medical Affairs team at medical@protexin.com.

14. Manfredo Vieira S, Hiltensperger M, Kumar V, et al. Translocation of a gut pathobiont drives autoimmunity in mice and humans. Science (80- ). 2018;359(6380):1156-1161. doi:10.1126/science.aar7201. 15. Czaja AJ. Factoring the intestinal microbiome into the pathogenesis of autoimmune hepatitis. World J Gastroenterol. 2016;22(42):9257-

References

9278. doi:10.3748/wjg.v22.i42.9257. 16. Lunia MK, Sharma BC, Sharma P, Sachdeva S, Srivastava S.

1. Marchesi JR, Adams DH, Fava F, et al. The gut microbiota and

Probiotics prevent hepatic encephalopathy in patients with

host health: a new clinical frontier. Gut . 2015:1-10. doi:10.1136/

cirrhosis: a randomized controlled trial. Clin Gastroenterol Hepatol.

gutjnl-2015-309990.

2014;12(6):1003-8.e1. doi:10.1016/j.cgh.2013.11.006.

GASTROENTEROLOGY TODAY - AUTUMN 2018

In summary, the link between autoimmunity and a dysbiotic gut

12. Ghouri YA, Richards DM, Rahimi EF, Krill JT, Jelinek KA, DuPont

FEATURE

FIT NEGATIVE FOLLOW-UP Safety-netting patients with a low faecal haemoglobin concentration and modifying the current patient pathway to improve patient care. Dr. James Turvill has been a consultant gastroenterologist at York Teaching Hospital NHS Foundation Trust since 2000. He has an interest in inflammatory bowel disease and gastrointestinal cancer. He is a screening endoscopist within the Bowel Cancer Screening Programme. Since 2008 he has developed a research interest in the use of biomarkers to facilitate the diagnosis and monitoring of gastrointestinal disease. Currently he is working with Y&H AHSN in the implementation of a faecal calprotectin (fCAL) care pathway to support NICE DG11 and with the Y&H Cancer Alliance in the introduction of faecal immunochemical testing (FIT) in patients with suspected colorectal cancer. Here Dr. Turvill summarises his presentation made at the Digestive Diseases Day held by Alpha Laboratories in November 2017, where he discussed his study at York Hospital and the importance of negative FIT follow-up for patients.

cohort will have non-enteric disease and within this group there will be other cancers, which FIT will not identify. This means that around 40% of all the cancers in patients referred through NICE NG12 with suspected CRC will be non-CRC.

Background

Therefore, the success of using FIT will not depend on how well it identifies CRC but on how well it helps us identify the 40% of cancer patients without CRC that are currently being referred through NG12.

“NICE guidance is about finding people with cancer so that we can make a difference. FIT should be seen as a technology designed to facilitate this process. So I am a little unsettled about the concept of using FIT as a test to ‘rule-out’ colorectal cancer (CRC), though this is what it is good at. Instead we need to use it to ‘rule-in’ patients and so find CRC early. And here lies the challenge.

Introduction

GASTROENTEROLOGY TODAY - AUTUMN 2018

In thinking about FIT negative follow up we need to understand what is currently happening in primary and secondary care and then, what a FIT positive result will mean for the future. Then for the FIT negative patient we need to consider consequentialism over essentialism. If you look at a cohort of patients referred from primary care fulfilling NICE NG12, that is at high risk of CRC, around two-thirds of patients will have ‘functional disorders’ (predominantly the irritable bowel syndrome (IBS), but also benign anal canal bleeding and iron deficient anaemia of unknown cause). Currently it is this group of patients that secondary care clinicians are focussing on since these are judged to increase healthcare costs by the time constrained consumption of resource in achieving a diagnosis. Then 4% of patients will have CRC and a further 4% will have significant polyps (those 10mm or larger). Then there will be a complex, non-malignant group of patients, making up 12%, generally termed ‘organic enteric disease’ that will need secondary care intervention. This includes patients with IBD, microscopic colitis and diverticulitis. There will be another similarly sized group with diminutive polyps (<1 cm). Lastly, around 4% of the

So how does FIT allow us to untangle this disparate group? We have looked prospectively at 700 patients referred from primary care under NG12 with suspected CRC. Each patient provided two stool samples prior to investigation allowing us to perform two FIT and two fCAL tests. We had hypothesized that a repeat test might improve the specificity-sensitivity profile of the assays and so enhance diagnostic accuracy. We tested FIT using the Kyowa Medex HMJACKarc and calprotectin using BÜHLMANN fCALl® ELISA (both supplied by Alpha Laboratories Ltd). If we extrapolate our data to a population of 1000 patients and apply ‘detectable’ haemoglobin as the FIT cut-off value you get 290 positive, and 710 negative results. You will pick up almost all, but importantly not all, CRC (I am reconciled to the fact that regardless of what the cut-off is, some, but very little CRC will be missed). Using this FIT cut-off most ‘IBS’ patients and those with diminutive polyps will be spared, initially at least, investigation. But FIT will miss half of those with organic enteric disease, over half of those with significant polyps and, importantly, half of those with other non-enteric cancers. So clearly FIT is a game changer. But not perfect. If you apply FIT using 10 µg/g cut off, the proportion of missed CRC will double. But the numbers will still be very small. Three patients in 1000 will be missed who would have been picked up using FIT for ‘detectable’ haemoglobin. But you will have reduced the number of FIT positive patients with IBS to a third. The total number of patients with

FEATURE a positive FIT will now be 140 patients. This then allows you to start to

So the key question is whether we will give this disparate group of

use healthcare resource much more efficiently. You have the starting

patients, time to declare themselves. Will we treat them expectantly or

potential to spare 860 patient investigations from the original 1000

will they all be sent for abdominal-pelvic CT scans to find the non-enteric

patient cohort. That resource can be directed at other patient groups,

cancer in a newly defined suspected cancer pathway?

such as those fulfilling NICE DG30. Our findings suggest that using the FIT ≥10µg/g cut off you get the optimal sensitivity (82%) and specificity

Surely for FIT to be of any health economic benefit the clinician must

(88%), with a high NPV (99%) and an acceptable PPV (27%).

be able both to apply clinical judgement if suspicious and so refer into a two week wait pathway, even if FIT negative, but also to treat

FIT negative patients So I have made the presumption that FIT negative care begins when a

symptomatically and review locally if judged appropriate. In this way patient care is central and FIT supports the efficient use of resource.

high risk patient has one FIT <10 µg/g. And who is going to carry that risk? In our putative population of 1000 patients we now have 860 such

Will primary care carry this cohort of FIT negative patients in whom

patients and within this group <1% will have CRC, 3% will have

it is known that there is missed cancer and in whom referral would

significant polyps and 3% non-CRC cancer. A significant number of

otherwise have taken place if NICE NG12 were applied? Should GPs

patients with organic enteric disease will remain, but over 90% will

refer all patients anyway, FIT positive or negative alike, but the former

have ‘IBS’.

urgently and the latter routinely? Or perhaps GPs should both retain clinical suspicion and initial management decision; treating FIT negative

What do we do next? What if you repeat the FIT or add in a fCAL?

patients symptomatically without automatic referral. Some would be

If you repeat the FIT and you are looking solely for CRC you will want

referred urgently and others routinely should they remain symptomatic

either of, rather than both, of the two FIT to be positive (to ‘rule in’ not

or early if suspicion was high. Would CT requesting from primary care

‘rule out’). In so doing we found that you could marginally increase

become the norm?

the sensitivity and specificity of FIT, but not significantly. Furthermore the repeat FIT requires additional cost, time and may reduce patient

In my mind what is needed is for clinical suspicion to help safety-net

compliance. We conclude that in symptomatic patients at high risk, a

the patient and this would be my preferred option. When thinking this

repeat FIT prior to referral would fail to detect CRC in those who were

through it is important to recognise the strength of primary care as ‘the

initially FIT negative. Perhaps their biology is different. Two FITs may

good gatekeeper’ while secondary care is the obligate investigator. So

prove useful for screening (it may offer cost savings) but not in the

this measured, safety netted, clinical risk assessment of FIT negative

work up of symptomatic patients.

patients should lie with primary care.

Adding fCAL gives no diagnostic advantage because it reduces the PPV. Can you identify the FIT negative patients with CRC if you apply particular patient symptomatology? The short answer here is no. Symptoms are no less specific in FIT negative patients than they are in the unselected cohort. Neither are we currently able to improve the sensitivity and specificity of FIT based on symptomatology (although this may come). Currently where there is rectal bleeding. However we found no difference in

Currently the role of FIT both to support DG30 and most particularly NG12 is uncertain. A great deal of work is going on at the moment and we will have a much clearer idea soon. I have it in mind that a pathway will develop something like the diagram below. The future pathway will start with patients with lower gastrointestinal symptoms in the broadest sense (though there may be a number of exclusions such as rectal mass/ iron deficient anaemia and

those presenting with or without rectal bleeding.

possibly fresh rectal bleeding in the young).

Managing FIT negative patients for the future

We know that the specificity of FIT is lower in younger patients so you

In thinking about the negative FIT we need to leave the technology

have to factor in a pragmatic age cut-off where fCAL may become a

behind and return to the patient. Perhaps we need to look again

more useful test. I have chosen 50 years.

at NICE CG27, the NICE guidance that pre-dated NG12. Here it states that ‘in patients with equivocal symptoms who are not unduly

All patients over 50 years with lower gastrointestinal symptoms, where

anxious, it is reasonable to use a period of ‘treat, watch and wait’ as

there is diagnostic uncertainty, irrespective of whether they currently do

a method of management’. Quite what this will mean in practice is as

not fulfil NICE NG12, will have a FIT. I do not think rectal bleeding will

yet uncertain. But the majority of patients will have functional disease

prevent the use of FIT.

and some will settle with expectant management. As many as 90% of younger, low risk patients will respond to local supportive measures

GP will also include patients younger than 50 years where CRC is

but it is uncertain how many will do so in this population. Perhaps

suspected. Because FIT is such a good diagnostic I think it acceptable

50%, optimistically.

to widen the net and not to be proscriptive.

GASTROENTEROLOGY TODAY - AUTUMN 2018

for example FIT cannot be applied in the low risk population (DG30)

The future?

FEATURE

GastroToday_July2_2018 02/07/2018 16:48 Page 1

Those who are FIT positive will be referred into the ‘two week wait’ pathway. Those under 50 years and in whom CRC is not suspected should enter the fCAL pathway. For those who are FIT negative, if cancer is still suspected then an urgent referral should be made anyway. Perhaps a CT will be the first investigation here. Otherwise these patients should be treated symptomatically and then reviewed within primary care. If still symptomatic and under 60 years they should then enter the fCAL pathway but if older than 60 years a routine referral should be made. In time I suspect a workable and pragmatic pathway such as this will GASTROENTEROLOGY TODAY - AUTUMN 2018

evolve. Overall, Dr Turvill concludes FIT is an excellent test and will capture almost all CRC. However, we must remain cognisant of its limitations and ensure that FIT negative follow-ups are conducted to avoid excess referral, and therefore dilution of the benefits of FIT, and encourage the partnering of FIT with clinical suspicion to ensure we capture as many of those cancers as possible. A video of Dr. Turvill’s presentation can be seen at www.faecal-immunochemical-test.co.uk/events. To find out more about introducing FIT into your patient pathway please visit www.faecal-immunochemical-test.co.uk or email digestivedx@alphalabs.co.uk

FEATURE

BRAIN, GUT OR MICROBIOME, WHERE SHOULD WE TARGET IN IRRITABLE BOWEL SYNDROME (IBS)? Simon Smale, Consultant Gastroenterologist Irritable bowel syndrome (IBS) is a chronic disorder characterised by

The onset of symptoms in IBS is often associated with psychological

abdominal pain and change in bowel habit as a consequence of abnormal

stressors. Chronic stress is associated with stress induced

visceral sensation and or motility as a result of abnormalities within the

hyperalgesia. This hyperalgesia is mediated via the corticotrophin

enteric or central nervous systems or both. Usually this occurs in the

releasing hormones and the hypo-thalamic pituitary axis (HPA).

absence of “organic” disease but association with other gastrointestinal

Dysfunction within these systems are well documented in patients with

disease is common. Disturbances in the gastro-intestinal microbiome have

IBS and other chronic pain syndromes. Furthermore many patients with

been identified in patients with irritable bowel syndrome, and it is often the

severe irritable bowel syndrome have histories of early life traumatic

case that symptoms may be triggered by events which lead to changes in

events. These events may result in changes that profoundly effect brain

microbiome, emotional context and enteric nervous function in tandem.

development and then predispose to visceral pain syndromes.

Many patients experiencing gastrointestinal inflammation as a result

Central pain amplification occurs through a wide variety of mechanisms within the central nervous system and mediates the effects of mood, emotional context, and environmental circumstances upon our central pain perception. fMRI studies have demonstrated patients with IBS often display an exaggerated response of the arousal circuits (associated with the HPA) and activation of endogenous pain pathways in response to visceral stimulation. Similarly studies have shown enhanced anticipation of pain in response to conditioning stimuli in patients with functional gastro-intestinal disease. Neuro-immune activation within the central nervous system is associated with altered astrocyte and microglial activity that further enhances central sensitisation.

of infection or inflammatory bowel disease (IBD) develop symptoms of irritable bowel syndrome. Nearly a quarter of patients with irritable bowel syndrome without identifiable “organic” disease appear to have low grade intestinal inflammation as judged by faecal inflammatory markers (calprotectin). Inflammation may lead to sensitisation of peripheral nerves, most inflammation within the gastro-intestinal tract settles, but in susceptible individuals sensitisation of peripheral afferents may persist. Such sensitisation may be driven by ongoing mast cell activation and

‘

increased epithelial permeability associated with low level inflammation.

The Complete FIT Solution Publications demonstrate the high NPV performance of faecal immunochemical testing (FIT), with symptomatic patients for cancer, HRA and IBD. With many years’ experience in bowel cancer testing Alpha Laboratories is partnering with Croydon University Hospital and RM Partners Cancer Alliance to recruit additional patient evidence. To date over 6,000 patient results have been generated. See the latest data at www.nicefitstudy.com

Forr the best support in establishing your FIT service contact the experts for a full end-to-end solution: ■ Simple, hygienic sample collection device □ Stabilises faecal haemoglobin: □ 14 days at ambient, 120 days at 2-8C ■ Assay with excellent low end sensitivity - 7 ng/ml ■ Custom designed patient instructions ■ Complete patient packs ■ Logistics solutions tailored to your requirements

Everything you need to know about FIT: W: faecal-immunochemical-test.co.uk | E: digestivedx@alphalabs.co.uk The FIT Solution.indd 1

21/09/2018 14:15:15

GASTROENTEROLOGY TODAY - AUTUMN 2018

Since the introduction of NICE DG30, the roll out of FIT has been expanding in NHS trusts and private clinics nationally.

The first 1 litre PEG bowel preparation1–3

FEATURE

Cut the volume keep the efficacy PLENVU® offers:

Come and visit Norgine at BSG 2018 on stand

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.

A18

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 - AUTUMN 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

FEATURE So where does the microbiome fit?

Those factors known to provoke irritable bowel syndrome have profound effects on microbiome

As well as direct effects on neurons proximal

function; gastroenteritis results in depletions in

to the bowel it is now clear that bacteria and

the microbiome, psychological stress can lead

their products have a profound effect on the

to significant changes in the representation of

development and activity of the central nervous

different phyla within the microbial flora. These

system and consequently upon psychological

potentially detrimental changes may facilitate

state and behaviours. At the level of the gut,

feedback from the gut and thence permit the gut

within the enteric nervous system certain bacterial

to have effects on mood, behaviour and cognitive

strains may directly promote sensitisation (or

functions.

alternatively down regulation) of peripheral afferents. Significantly the low grade inflammation seen in a proportion of patients with IBS may result from the ability of specific bacteria to enhance production and the effects of proinflammatory cytokines. Bacteria may also be able to transmit signals via the enteric nervous and immune systems to the central nervous system. Within the central nervous system the gastrointestinal microbiome influences early brain development. Evidence from mammals demonstrates that maternal diet influences the behaviour of their offspring, mouse mothers fed on high fat diets have offspring with poor social skills. These behavioural changes appear to be manifest by changes in the microbiome. Correction of “bacterial deficits” leads to improvements in behaviour. We know that early deprivation in patients with IBS can have profound effects on the microbiome and recognise that these factors may predispose susceptible individuals to more severe

Within an individual eliciting the effects of early development, environmental stressors, diet, neurological development and genetic predispositions is often challenging within the context of a twenty minute clinic appointment. So what can we do? A careful history often elicits psychological stresses or dietary factors which may exacerbate symptoms. Investigations to exclude organic disease may be appropriate. Lifestyle is key to maintaining well-being and we would do well to encourage our patients to address poor sleep, find time to relax and take regular exercise. Specific medication may help target specific symptoms. Dietary manipulation may enable modification of symptoms, either by effects on the biome or simply by avoiding foods known to trigger dysmotility or mal-fermentation in the colon. In any event patients with IBS will continue to need support in managing their symptoms. Beyond the clinic, The IBS

IBS. Changes in central nervous system function

Network, the national charity which supports

arise as a result of microbial products which then

patients with IBS provides a self care program

influence astrocyte, microglial and central nervous

which helps patients to manage the complex

system inflammatory responses. Certain bacterial

lifestyle challenges they face. Whilst our current

strains, possibly as a result of being able to

understanding and the available technology have

modulate these effects may influence behaviour.

not yet enabled us to predict how changing the

Specific bacterial strains have been demonstrated

biome in specific ways for specific individuals may

to increase resilience in individuals with anxiety

resolve symptoms, advances in our understanding

and these behavioural changes have been shown

hold promise that one day the answer for IBS

to have neurological correlates on fMRI studies.

sufferers may lay in a bug if not a pill. GASTROENTEROLOGY TODAY - AUTUMN 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 Coeliac disease diagnosis rises to 30% - but still missing half a million Coeliac UK, the largest independent charity for people who need to live gluten free, has announced recent research shows diagnosis of the autoimmune disease, coeliac disease, which affects 1 in 100 people, has risen in the UK from 24%¹ in 2011 to 30%² in 2015. The research, commissioned by the charity, from the University of Nottingham, searched UK patient records up to and including 2015 for clinical diagnoses of coeliac disease and dermatitis herpetiformis (the skin manifestation of coeliac disease).

The NICE guidelines for coeliac disease

It’s a tough disease to diagnose and

and IBS recommend that anyone presenting

treat and less than seven per cent of

with IBS symptoms should be screened first

people will survive beyond five years.

for coeliac disease.

Despite being the 11th most common

“It is essential that people with chronic gut

cancer much needs to be done to raise

conditions - whether that’s coeliac disease

awareness of the disease, its symptoms

or IBS - get an accurate diagnosis as

and treatment pathways. The first clinical

quickly as possible. Having the right tests

NICE guidelines specifically outlining

allows healthcare practitioners to put the

recommendations for pancreatic cancer

right treatment in place and patients can

care were published earlier this year

learn how to best manage their condition,”

(February 2018), marking a step change

said Alison Reid CEO The IBS Network.

in the care of people diagnosed with the disease.

Coeliac disease is a serious autoimmune condition caused by a reaction to gluten,

The NICE Recommendations

a protein found in wheat, barley and rye.

Pancreatic Cancer UK believes that the

People diagnosed with coeliac disease

NICE guidelines will improve the present

must maintain a strict gluten free diet for

management of pancreatic cancer by

the rest of their life if they are to avoid very serious complications such as osteoporosis, infertility and although rare,

The research showed that although

small bowel cancer.

diagnosis rose by a quarter in four years (2011-2015), alarmingly the rate

“The blood test for coeliac disease is

of diagnosis was slowing significantly,

relatively quick and cheap and we urge

resulting in around half a million people in

anyone that has ongoing symptoms to

the UK still living with undiagnosed coeliac

visit their GP and request to be screened

disease.²

for coeliac disease. Next year we will be launching a campaign targeting the medical

It also highlighted that 1 in 4 adults over

profession to encourage them to consider

18 years diagnosed with coeliac disease

if their patients could be suffering with

had previously been misdiagnosed with

undiagnosed coeliac disease or have been

Irritable Bowel Syndrome (IBS), the same

misdiagnosed with IBS and ensure that

percentage that had been reported in

they do not to remove gluten from their diet

research from 2013.³

prior to testing as this could lead to a false negative result,” continued Ms Sleet.

Sarah Sleet, chief executive of Coeliac UK said: “It’s fantastic that the research shows that around 45,000 people were diagnosed between 2011 and 2015. But with half a million people in the UK still GASTROENTEROLOGY TODAY - AUTUMN 2018

without a diagnosis we’ve got a long way to go. The fact that testing for the condition is slowing and nothing has changed in people being diagnosed with IBS before being tested for coeliac disease, suggests the NHS is failing to address the mountain of underdiagnoses. We know this is even more urgent today as recent research is uncovering some symptoms of coeliac disease, specifically neurological ones that cannot be reversed without an early diagnosis.”

Although many people present with a range of symptoms including those that are gut related, other symptoms include mouth ulcers, anaemia, repeated miscarriages and neurological problems. The charity’s online assessment www.coeliac.org.uk/isitcoeliacdisease allows people to quickly check if they should go to the GP and ask for a blood test.

Charity produces a patientfriendly version of the NICE guidelines for pancreatic cancer

It still takes 13 years on average for

highlighting best practice and clinical evidence, lead to a consistency in treatment and care, and reduce the time from diagnosis to treatment. The guidelines include recommendations on managing key symptoms of the disease which should help improve quality of life. This includes providing support for the psychological impact of pancreatic cancer, and managing dietary symptoms with pancreatic enzyme replacement therapy. The guidelines include recommendations for patients to have access to a specialist team of healthcare professionals and provide guidance on the best way to treat operable and inoperable pancreatic cancer. There are also specific recommendations for relieving duodenal and biliary obstruction, as well surgical resection and adjuvant chemotherapy. One particular recommendation which will transform care is that people who have suspected pancreatic cancer but have had an unclear CT scan should be offered a FDG-PET/ CT scan. This will improve the diagnosis pathway, offer more information on each person’s tumour and show whether the cancer has spread. The guidelines play a crucial role in promoting best practice for the care of people diagnosed with pancreatic cancer within the health professional sector. Pancreatic Cancer UK believes that patients and families should also have access to the guidelines. This can help

a person with coeliac disease to be

Each year around 10,000 people are

them understand more about the care they

diagnosed.

diagnosed with pancreatic cancer in the UK.

should have and make informed decisions

NEWS

INVITATION

Microscopic Colitis Roadshow Tillotts Pharma UK invites you to attend the microscopic colitis educational roadshow to find out more about the latest developments in the field of microscopic colitis. Join us at one of the events below where Dr Andreas Münch and a local expert will explore current thinking on the pathophysiology of this chronic condition, the challenges of treating patients with microscopic colitis and the pathways being forged in research.

Dr Andreas Münch Consultant Gastroenterologist and President of the European Microscopic Colitis Group (EMCG), Linköping University Hospital, Sweden

Belfast, Hilton Hotel

Birmingham, Radisson Blu Hotel

Monday 26th November

Tuesday 27th November

Local speakers: Dr Patrick Allen & Dr Maurice Loughrey

Local speakers: Dr Rachel Cooney & Professor Shaji Sebastian

Registration from 6:00pm

Manchester, Doubletree by Hilton

Newcastle, Crowne Plaza

Wednesday 28th November

Thursday 29th November

Local speakers: Dr Matthew Kurien & Rachel Campbell

Local speakers: Professor Pali Hungin, Dr John Mansfield & Professor Shaji Sebastian

Registration from 6:00pm

Friday 30th November Local speakers: Dr Evangelos Russo & Professor Anton Emmanuel Registration from 12:30pm

GASTROENTEROLOGY TODAY - AUTUMN 2018

London, The British Library Register now for free at: http://TillottsMCweek.eventreference.com/ or let your local Tillotts Pharma UK Ltd representative know your interest

amme by

This educational event is organised and funded by Tillotts Pharma UK Ltd.

Prepared September 2018 | NU-00231

NEWS about treatment options. However, the

have been diagnosed with pancreatic

content is relevant and easy to understand.

guidelines contain medical and technical

cancer. Already we are seeing a positive

terms which can be too complicated for

response from health professionals about

The charity also offers its information

many people to understand. Therefore, the

the guidelines. Naturally the next step was

charity has developed a patient-friendly

to produce a version of the guidelines

version of the guidelines, in plain English,

accessible for patients and carers.”

designed to help people easily identify the recommendations that are relevant to them

Information from Pancreatic Cancer UK

and their stage of cancer.

The patient-friendly version of the NICE

in large print, audio and braille making it accessible to people with additional needs, and so can support healthcare professionals in meeting Accessible Information Standard requirements.

guidelines can be downloaded or ordered

About Pancreatic Cancer UK

Creating the patient-friendly version

for free from the Pancreatic Cancer UK

Pancreatic Cancer UK is accredited by

website. The patient-friendly guidelines are

Pancreatic Cancer UK is taking on

the Information Standard, a certification

also available in conjunction with Pancreatic

programme supported by NHS England,

Cancer UK’s Patient Charter which explains

as producers of trustworthy, high quality

the standard of care all people with

health and care information. To develop

pancreatic cancer should have.

pancreatic cancer through research, support and campaigning to transform the future for people affected. The charity provides expert, personalised support and information via a Support Line (Freephone

the patient-friendly guidelines Pancreatic Cancer UK worked closely with health

The charity provides a variety of free

0808 801 0707) and the website

professionals on the NICE committee as

publications for patients and health

pancreaticcancer.org.uk/

well as people who have been affected by

professionals covering diagnosis, treatment

the disease such as patients and carers.

options, managing symptoms and end of life care. The resources have been reviewed

Pancreatic Cancer UK’s Annual Summit, taking place on 1st March 2018, brings

Anna Jewell, director of operations at

by healthcare professionals to ensure

Pancreatic Cancer UK, and lay member of

all the information is accurate and up to

the NICE guidelines committee said: “The

date. People who have been affected by

policy makers, charities and people

introduction of the new clinical guidelines

pancreatic cancer first hand play a key part

affected by the disease. Find out more on

should transform care for people who

in the review process, to confirm that the

the Pancreatic Cancer UK website.

together health professionals, researchers,

GUIDE TO CONTRIBUTORS Original papers, reviews, audits, case reports and correspondence should all be sent to: The Editor, Gastroenterology Today Media House, 48 High Street, Swanley, Kent, BR8 8BQ All material will be reviewed for possible publication on the understanding that it has not been submitted to another publication or been previously published in whole or in part (unless in abstract form) and a covering letter, signed by all the authors, to that effect should accompany the item(s).

GASTROENTEROLOGY TODAY - AUTUMN 2018

Manuscripts can be accepted in most commonly available Word Processing programs via E-mail to MPCjournals@aol.com. Information on the program used should be provided. Photographs and illustrations can also be emailed to the same address. Legends for photographs and illustrations shown separately and the photographs annotated accordingly. They must be marked for orientation. Any hardcopy material should be typed in double-space, with wide margins and all pages must be numbered. The title page should include the name(s) of the author(s) together with their current addresses or hospitals and positions held. All correspondence will be addressed to the first-named author unless otherwise directed. Manuscripts, disks and photographs will be returned if requested. All material will be destroyed three months after publication unless the publishers receive other instructions as to its disposal. References: References should broadly follow the Vancouver System and should be shown throughout the text consecutively, typed in square brackets, and listed numerically at the end of the article. If there are fewer than FIVE authors all names should be given in full. Where there are more than five authors, the full names of the first five only should be given, followed by et al. Journal titles should be given in full and be followed by the year of publication, the volume (and/or supplement) number and the page numbers. Editors, publishers, publication dates and country of origin should follow book titles. Abbreviations and Symbols: Authors should refer to Units, Symbols and Abbreviations published by the Royal Society of Medicine.

NEWS

GASTROENTEROLOGY TODAY - AUTUMN 2018

NEWS Funding awarded to seven research projects Investigations into the causes and treatment of Crohn’s and Colitis will receive a total of £643,230 from Crohn’s & Colitis UK. Besides world-class research into the causes and treatment of IBD, Crohn’s & Colitis UK funds and conducts studies that examine living with the conditions. Projects set to receive funding in 2018 Aston University receives £33,790 to plan and test ways to help young people with Crohn’s and Colitis stick to their treatment plans. “Managing IBD adds complexity to an already demanding phase of life,” says Dr Gemma Heath, principal investigator. The project will develop a tailored programme to support treatment adherence, and help young people with IBD to become managers of their own long-term condition. Sheffield Teaching Hospitals NHS Foundation Trust is awarded £119,967 to develop and pilot test a tool to support patients with Ulcerative Colitis in choosing between ongoing medical treatment and surgical treatment options.

Around 20-30% of patients with UC will undergo surgery, the majority electively. The Sheffield team, under Professor Alan Lobo, will develop a ‘patient decision aid’ to show the risks and benefits associated with each treatment option. St George’s, University of London receives £89,670 to investigate the relationship between depression and antidepressant medication and clinical outcomes for patients with Crohn’s and Colitis. Principal investigator Dr Richard Pollok says: “We will see if using antidepressants leads to fewer IBD ‘flares’ and less surgery [and] examine the effect of Crohn’s and Colitis-related surgery, in particular having a stoma, on developing depression and the need for antidepressants.” The University of Exeter is awarded £120,000 to develop personalised strategies to reduce ‘immunogenicity’ (an immune response) to anti-TNF drugs, which causes patients to lose response to the medication over time. It’s thought that genetic factors may determine why some patients develop antibodies against anti-TNF drugs. Research lead Dr Tariq Ahmad says that knowing which patients are at high risk of immunogenicity would, in future, lead to targeted use of immunosuppressant drugs. The University of Cambridge receives £87,463 to study five regions of DNA that are

associated with Crohn’s and Colitis and a range of other diseases, such as multiple sclerosis and rheumatoid arthritis. “These regions are particularly challenging because they do not contain genes,” says principal investigator Dr James Lee. He will use a new technique developed at Harvard University to establish how these five tiny variants in the DNA of Crohn’s and Colitis patients contribute to disease development. The aim is to identify new targets for IBD treatments. Queen Mary University of London is awarded £73,573 to investigate drugs that might delay, prevent or possibly reverse the process of fibrosis (when scar tissue develops in the bowel due to tissue damage caused by inflammation) in Crohn’s Disease patients. Fibrosis can cause a narrowing (stricturing) of the bowel and a blockage – the leading cause of Crohn’s surgery. This research will look at how valporic acid (VPA) affects the chemical processes in the gut wall cells that result in fibrosis. It may lead to VPA becoming a treatment for fibrosis in Crohn’s patients. MRC Centre for Inflammation Research at the University of Edinburgh receives £118,767 to build on previous work funded by Crohn’s & Colitis UK. The study examines how the gut’s ‘danger signals’ (cell mitochondria) cause inflammation and how drugs could block this inflammatory response.

WHY NOT WRITE FOR US? GASTROENTEROLOGY TODAY - AUTUMN 2018

Gastroenterology Today welcomes the submission of clinical papers and case reports or news that you feel will be of interest to your colleagues. Material submitted will be seen by those working within all UK gastroenterology departments and endoscopy units. All submissions should be forwarded to info@mediapublishingcompany.com

If you have any queries please contact the publisher Terry Gardner via: info@mediapublishingcompany.com

NEWS

7-8 March | Sage, Gateshead

British Society of Gastroenterology invites you to the 3rd BSG Endoscopy Live meeting, to be held at Sage, Gateshead on 7 – 8 March 2019. Live endoscopy from the University College Hospital, London and Freeman Hospital, Newcastle World-class UK & international faculty

Through live procedure demonstrations, practical tips and state-of-the-art reviews, this interactive meeting will showcase UK endoscopy and challenge, debate and inform all areas of endoscopic practice including:

The very best of diagnostic and therapeutic endoscopy will be demonstrated via live links to two of the UK’s leading endoscopic centres, Freeman Hospital, Newcastle and University College Hospital, London.

www.bsg.org.uk @BSGEndo

‘Meet the expert’ sessions with the opportunity to ask those all important questions

The programme will also include clinical updates, breakout sessions and symposia presented by an outstanding UK and international expert faculty. The full programme and online registration details will follow soon. Meanwhile, please save the date and we look forward to seeing you at Sage, Gateshead on 7 – 8 March, 2019! Ian Penman Chair, Organising Committee BSG Endoscopy Live 2019

GASTROENTEROLOGY TODAY - AUTUMN 2018

• Training • Quality • Interventional techniques • Novel technologies and devices

State of the art interactive lectures covering endoscopic training, practice & innovation

POSTERS

IMMUNE CHECKPOINT INHIBITO

R. NATHWANI1, L. AU2, C. BARLOW3, T. TILLET4, R. BOWEN4, L. SPAIN2, J. THOMAS2, M. BACKHOUSE3, A. GURUNG3 1 IMPERIAL

COLLEGE LONDON. 2 THE ROYAL MARSDEN HOSPITAL. 3 MUSGROVE PARK HOSPITAL. 4 ROYAL UNITED HOSPITALS BATH

3. Results

1. Background

•

The immune system is an effective target in oncology therapy.

•

Checkpoint pathways, including the cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) pathway, which downregulates early T-cell function, and the programmed death 1 (PD-1) pathway, which regulates T-cell activity at the effector phase, can be coopted by tumours to elude an immune response.

•

57 patients experienced CPI induced acut December 2017.

•

Autoimmune pathology was excluded bioch

immunoglobulin and autoantibody levels, an •

Demographics details were as follows (tabl Demographics

Checkpoint inhibitors (CPI) target immune cell check points and restore anti-tumour

Sex • Male • Female

immune responses. •

•

Current indications for checkpoint inhibitor use include (Figure 1): •

Metastatic melanoma

•

Non-small cell lung cancers

•

Bladder cancer

•

Renal cell carcinomas

•

Relapsed Hodgkin's Lymphoma

•

Head and neck cancers.

Median Age

Treatment • Monotherapy (CTLA-4 or PD-1 Inhibitor alone) • Combination therapy (CTLA-4 + Inhibitor) Median ALT Median ALP Figure 1. Current indications for Checkpoint Inhibitor Use.

Most commonly used are the anti-CTLA-4 monoclonal antibody ipilimumab and anti-PD-1 monoclonal antibodies pembrolizumab and nivolumab, all of which are approved for the treatment of advanced melanoma.

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CPI-induced acute liver injury (ALI) is the second most frequent immune-

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CPI therapy was most commonly used for

•

Number of days to acute liver injury for th

22 days, p = 0.0087 in those receiving com •

related adverse event: •

5% incidence - single agent use (e.g. nivolumab, pembrolizumab)

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25% incidence - dual agent use (ipilumimab + nivolumab)

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• There is no reported data on ALI disease pathogenesis, clinical evolution and outcome of patients treated with CPI therapy. GASTROENTEROLOGY TODAY - AUTUMN 2018

• Our multicentre cohort study evaluated clinico-pathological aspects of CPI-induced ALI.

•

Bilirubin 64

•

INR 1.5

44/57 patients (79%) received intravenou •

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Median dose received was 1.3mg/kg

Grade 4 ALI was treated with higher dos vs 1.2mg/kg.

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21/57 patients (37%) received Mycophen sparing agent.

2. Method • A retrospective analysis was performed of patients with CPI induced ALI presenting

•

Treatment by ALI Grade was as follows (tab ALI Grade

to 6 UK oncology centres between 2013 and 2017. • Indices of acute liver injury, treatment related complications and outcome were recorded. • Severity scoring of liver injury was based on Common Terminology Criteria for Adverse

No. receiving S

Grade 1

1/7 (14.3

Grade 2

10/14 (71.

Grade 3

24/26 (92.

Grade 4

10/10 (100

Events (Table 1 - ALI grade 1-4): • Hepatitis

Grade 1

Grade 2

Grade 3

Grade 4

AST or ALT < x3 Upper limits of normal (ULN)

AST or ALT > x3 to < x 5 ULN

AST or ALT > x5 to < x 20 ULN

AST or ALT > x 20 ULN

Table 1. Severity scoring of liver injury.

Only 1 patient developed acute synthetic

Steroid refractory ALI was treated with patients (7.0%). •

Fungal sepsis (Aspergillus) occurred

POSTERS

OR INDUCED ACUTE LIVER INJURY

3, R. MORRISON1, T. CROSS5, C. HERBERT6, R. GOLDIN1, M. GORE2, J. LARKIN2, S. TURAJILIC2,

C.G. ANTONIADES1

NHS FOUNDATION TRUST. 5 THE ROYAL LIVERPOOL UNIVERSITY HOSPITAL. 6 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION

•

te liver injury between January 2013 -

Patients with severe, refractory (grade 4) ALI had significant reductions in circulating peripheral lymphocytes and monocytes post steroid treatment (figure 2 and figure 3):

hemically, with normal serological

*p=0.0139

Lymphocyte Count

0.8

Table 2. Study population demographics

41/57 (72%) 16/57 (28%)

0.705 0.8

1.63

0.49 1

Grade 1+2

Grade 3

Grade 4

Grade of Liver Injury

+ PD-1

36/57 (63%) 325U/L (155 – 543) 111U/L (72 – 250)

the treatment of malignant melanoma.

Figure 2. Peripheral lymphocyte count 4 weeks post treatment.

•

0.4

0.0

Grade 1+2

Grade 3

Grade 4

Grade of Liver Injury

Figure 3. Peripheral monocyte count 4 weeks post treatment.

35/57 (65%) had temporal association between recent infection and ALI 8/57 (15%) had immunotherapy associated colitis prior to the onset of ALI.

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11/57 (21%) developed infection during

•

Anti-TNF-⍺ administration was not associated with more severe acute liver injury.

immunosuppression as summarised in figure 4: •

Pathological findings from 6 liver biopsies revealed lobular hepatitis and myelo-lymphoid aggregates.

•

us methylprednisolone or oral prednisolone.

The immune infiltrates from biopsy were CD68+ macrophages, CD3+ CD8+ T-cells.

•

ses of steroid vs Grade 2-3 ALI,1.5mg/kg

14/57 died during study period •

Figure 4. Infection sites during immunosuppression treatment.

13/14 (93%) died due to disease progression and only 1/14 (7%) due to

•

All deaths due to progressive disease were in patients with grade 3-4 acute liver injury.

ble 3):

• No. receiving MMF 0/7 (0.0%)

Median survival was significantly lower in grade 3-4 (14.5 months) vs grade 1-2 (25 months) ALI.

.4%)

1/10 (10.0%)

.3%)

10/24 (41.7%)

4. Conclusion

0%)

10/10 (100%)

• Our data report on the largest cohort of CPI induced ALI identifying disease evolution,

Table 3. Treatment regime by ALI severity grade

h Anti-thymocyte globulin (ATG) in 4/57

d in all 4/4 ATG treated patients (100%).

markers of disease severity and strong correlation with increased morbidity and mortality. • Further research is required to delineate triggers and pathogenesis of CPI induced ALI in order to develop calibrated therapies to ameliorate liver injury.

GASTROENTEROLOGY TODAY - AUTUMN 2018

immunotherapy related neuropathy

nolate Mofetil (MMF) as long term steroid

3%)

0.34

•

c dysfunction with no encephalopathy.

Steroids

0.4

development.

hose receiving monotherapy was 96 days vs

mbination therapy.

0.6

0.2

58.5 years 21/57 (37%)

** p = 0.0052

1.0

Monocyte Count

nd/or histologically.

le 2):

Monocyte Count 4 weeks Post Treatment

Lymphocyte Count 4 weeks Post Treatment 4

(Presenter Declarations: This presenter has no declarations of relationships with industry).

POSTERS

Are Extra-Pancreatic Malignanci with Intraductal Papillary Mucino Trevor Tabone1; Kelvin Cortis2; Neville Azzopardi3

1 Department of Medicine, Mater Dei Hospital, Malta; 2 Department of Radiology, Mater Dei Hospital, Malta; 3 Departmen

BACKGROUND

• The association between the presence of an intraductal papillary mucinous neoplasm (IPMN) of the pancreas and the prevalence of extra-pancreatic malignancies (EPM) remains unclear. • The need to screen for an EPM in such patients is controversial and could lead to an additional burden on resources given the increased incidental detection of IPMNs on cross-sectional imaging.

OBJECTIVES

• To determine whether the prevalence of EPM is higher in IPMN patients when compared to the general Maltese population. • Should IPMN patients undergo intensified radiological investigations in search for a possible underlying EPM?

METHODS

• Patients with an incidental radiological diagnosis on magnetic resonance imaging (MRI) between 2010 and 2017 were recruited. • Prevalence of a previous history or synchronous diagnosis of EPM was recorded by reviewing electronic histopathology results of biopsies or resection specimens. • EPM was defined as per ICD-10 C00-80 codes (International Statistical Classification of Diseases and Related Health Problems), thus excluding non-melanoma skin cancer and haematological malignancies. • All EPMs were based on a tissue diagnosis. • The prevalence of EPM was calculated and compared with the lifetime prevalence of developing EPM (ICD-10, C00-C80) in the general Maltese population. GASTROENTEROLOGY TODAY - AUTUMN 2018

175 patients with an incidental IPMN on MRI included in study population

• 36 out of 175 IPMN patients wer in a prevalence of 20.6%

• Commonest malignancies cons colorectal 25.0% (n=9), and re respectively.

• The calculated lifetime prevalen the general Maltese population i

• No statistical difference in EPM the IPMN patient cohort and (p=0.86).

• Baseline characteristics did not patients with an associated EPM a

36 out of 175 IPMN patient

• Single-centre, retrospective study.

DEMOGRAPHICS

RESULTS

Mean age at imaging 69.4 years (min: 36; max: 86)

55.6% female (n=20);

44.4% male (n=16)

Extra-Pancreatic Malignancy Breast Carcinoma Colorectal Adenocarcinoma Renal Cell Carcinoma Hepatocellular Carcinoma Prostate Adenocarcinoma Cholangiocarcinoma Gastrointestinal Stromal Tumour (GIST)

58.3% female (n=102); 41.7% male (n=73)

Appendix Carcinoid Urinary Bladder Transitional Cell Carcinoma Gallbladder Wall Adenocarcinoma

Mean age at incidental imaging: 66.8 years (min: 29; max 91)

88.6% Branch-Duct IPMN (n=155); 9.7% Main-Duct IPMN (n=17); 1.7% Mixed-Type IPMN (n=3)

Skin Melanoma Glioblastoma Multiforme Ovarian Adenocarcinoma

• Extra-Pancreatic Malignancies in IP

POSTERS

ies More Prevalent in Patients ous Neoplasm of the Pancreas?

Printing

nt of Gastroenterology, Mater Dei Hospital, Malta Skin Melanoma 2.8% Gallbladder Wall Adenocarcinoma 2.8%

re found to have an EPM, resulting

Appendix Carcinoid 2.8%

nce (risk) of developing an EPM in is 19.5% (1 in 5).

Gastrointestinal Stromal Tumour (GIST) 2.8%

M prevalence was found between the Maltese general population

Cholangiocarcinoma 2.8%

Hepatocellular Carcinoma 5.6%

ts associated with an EPM

.8% Mixed-IPMN (n=1)

Breast Carcinoma 30.6%

Prostate Adenocarcinoma 5.6%

significantly differ between IPMN and those with no EPM.

16.7% Main-duct IPMN (n=4);

Ovarian Adenocarcinoma 2.8%

Urinary Bladder Transitional Cell Carcinoma 2.8%

sisted of breast 30.6% (n=11), enal cell carcinoma 11.1% (n=4)

6.1% Branch-duct IPMN (n=31);

Glioblastoma Multiforme 2.8%

Renal Cell Carcinoma 11.1%

45.2% of Branchduct IPMNs (n=14) located in pancreatic head and/or uncinate process

Colorectal Adenocarcinoma 25.0%

• Percentage of associated extra-pancreatic malignancies in IPMN patient cohort

Percentage of IPMN Patients (%)

C50

30.6 (n=11)

C18; C20

25.0 (n=9)

C64

11.1 (n=4)

C22

5.6 (n=2)

C61

5.6 (n=2)

C22

2.8 (n=1)

C49

2.8 (n=1)

C07

2.8 (n=1)

C76

2.8 (n=1)

C23

2.8 (n=1)

C43

2.8 (n=1)

C71

2.8 (n=1)

C56

2.8 (n=1)

PMN patient cohort by ICD-10 code

CONCLUSIONS

EPMs do not occur more frequently in IPMN patients. There is no rationale for undergoing further extensive radiological investigations searching for an underlying EPM in patients with an incidentally identified IPMN on cross-sectional imaging.

•

REFERENCES

Nationalcancerplatform.org.mt. (2018). National Cancer Platform Malta | Cancer Stats in Malta. [online] Available at: http://www.nationalcancerplatform.org.mt/resources/cancer-stats-inmalta/ [Accessed 02 Feb. 2018]

•

Tanaka, M., Fernández-del Castillo, C., Kamisawa, T., Jang, J., Levy, P., Ohtsuka, T., Salvia, R., Shimizu, Y., Tada, M. and Wolfgang, C. (2017). Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology, 17(5), pp.738-753.

•

European evidence-based guidelines on pancreatic cystic neoplasms. (2018). Gut, 67(5), pp.789-804.

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