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GERD: A practical approach

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Here you will find a collection of informative Gastro articles featured in your favourite medical publication.

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Contents

4 GERD: A practical approach 6 PPIs vs primary reflux surgery 7 Biopsies not needed for majority of childhood coeliac diagnoses say experts 8 Key facts about probiotics and antibiotics 9 Novel treatment for ulcerative colitis 10 Treatment for heartburn 11 South Africans should prioritise gut health 12 The microbiome – obesity link 13 W hat role does the microbiome play in developing allergies?

14 IBS: More than a simple irritation 15 The importance of gut microbiota in early childhood 16 Poo is taboo 17 Bowel Prep for colonoscopy: What to consider 19 Bowel Prep education app is effective 21 Medical vs surgical: Treatment for refractory heartburn 22 Chronic constipation treatment should be natural 24 Antibiotics: Do probiotics protect against in diarrhoea?

26 Stopping reflux 27 Staying neutral 28 Probiotic reduces crying in colicky infants 29 How to improve bowel Prep 30 Causes of stomach pain 33 Gord vs heartburn: Know the difference 34 Crohn’s marker improves outcomes 36 Beating diarrhoea with probiotics 37 A first for SA: Minimally invasive procedure for haemorrhoids

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GASTROENTEROLOGY Focus

GERD: A practical approach Gastroesophageal reflux disease (GERD) develops when reflux of stomach contents causes troublesome symptoms. Some patients may also develop complications of GERD, but symptoms can occur without objective evidence of erosive oesophagitis. In Western countries it is estimated that 10-20% of adults experience symptoms of GERD at least once a week, but the prevalence is increasing parallel with the rising prevalence of obesity and decreasing prevalence of Helicobacter pylori infection.

T

ROUBLESOME SYMPTOMS AND COMPLICATIONS Common symptoms of GERD are regurgitation and heartburn, although these are insensitive markers of reflux. Symptoms may worsen on lying recumbent, especially after meals. Although dysphagia may occur in uncomplicated GERD, if it does the patient should be investigated to exclude more serious complications, including strictures, malignancy, or oesophageal dysmotility. Chest pain can occur, but cardiac causes must be excluded before the chest pain is attributed to GERD. Other symptoms include dyspepsia, nausea, bloating, sore throat, globus sensation and epigastric pain. The prevalence of GERD is similar in adults of all ages. However, even though they might have more severe GERD, elderly people are less likely to complain of symptoms. Extraoesophageal symptoms include asthma, laryngitis, pharyngitis, chronic cough, sinusitis, idiopathic pulmonary fibrosis, dental erosions, and recurrent otitis media.

PATHOPHYSIOLOGY Factors that are known to contribute to GERD include transient relaxation of the lower oesophageal sphincter (LES), sliding hernia, low oesophageal sphincter pressure, acid pocket (which develops due to poor mixing of acid with chyme in the proximal stomach), obesity and delayed gastric emptying. Although most symptomatic GERD is due to acid reflux, persistent symptoms during treatment with a proton pump inhibitor (PPI) are more likely to be due to weakly acidic or weakly alkaline secretions. Nevertheless, regardless of acidity of the bolus, the higher the reflux travels up the oesophagus, the worse the symptoms. Patients with GERD have been found to have heightened perceptions of normal nonacidic reflux events due to lower sensory thresholds.

It is also possible that GERD symptoms might arise from sustained contraction of longitudinal oesophageal muscles,

4 MEDICAL CHRONICLE

leading to transient ischemia of the oesophageal wall.

DIAGNOSIS AND MANAGEMENT Diagnosis is mainly a clinical one based on typical symptoms. Patients with no alarm symptoms should be given a trial of PPI therapy. This approach has 78% sensitivity and 54% specificity for GERD, and if typical symptoms resolve, the PPI therapy should be continued. However, patients with alarm symptoms (e.g., dysphagia, anaemia, weight loss, bleeding, and recurrent vomiting) and those who don’t respond to a PPI should be investigated with upper gastrointestinal endoscopy. Many patients with GERD symptoms have normal endoscopy. When oesophagitis is present, it is classified using the Los Angeles classification system.

Biopsies should be taken to exclude eosinophilic oesophagitis.

In patients with persistent symptoms and normal findings on endoscopy, 24-hour or 48-hour oesophageal pH monitoring should be considered before surgical or endoscopic interventions. pH testing is performed with the patient off PPI therapy when there is low clinical suspicion for GERD. In patients with refractory symptoms while on PPI therapy, and where there is a high likelihood of GERD, pH-impedance testing may be useful. p4v,w Barium oesophagography is not indicated for investigation of GERD. TREATMENT 1. Lifestyle intervention Weight loss can reduce or eliminate GERD symptoms. A structured weight loss program reduced symptoms in 81% of obese people with GERD and 65% had complete resolution of symptoms. Although symptomatic GERD patients have often been advised to avoid smoking and certain types of food, no consistent associations between specific foods and symptoms of GERD have been established. Furthermore, in clinical studies, cessation of smoking and alcohol were not associated with

improvement of GERD symptoms. Avoiding meals in the 2-3 hours before bedtime and elevating the head of the bed may be helpful in alleviating nocturnal symptoms.

2. Drug therapy PPIs are the therapy of choice for symptomatic relief and healing of erosive oesophagitis. They inhibit gastric acid secretion by inactivating the hydrogen potassium ATPase molecules of the parietal cell, and optimal acid suppression occurs when the proton pumps are activated as the parietal cell is maximally stimulated after a meal. Therefore, except for dexlansoprazole (which achieves sustained plasma drug concentrations and may be taken at any time of the day), for optimal PH control, PPIs should be taken 30-60 minutes before a meal. After 8 weeks of therapy, patients with GERD should aim to take the lowest dose required to manage their symptoms.

Some may be able to take the PPI when symptoms arise. However, patients with severe oesophagitis (grade C or D), Barret’s oesophagus and peptic strictures require long-term therapy. A recent randomised controlled trial found no association of PPIs with any adverse event when used for 3 years, with the possible exception of an increased risk of enteric infections. In particular, studies showed no association between long-term PPI use and myocardial infarction, small intestinal bacterial overgrowth, pneumonia, or gastrointestinal malignancies. Second-line therapies include histamine type 2 receptor antagonists and antacids.

3. If first-line therapy fails 40% of patients with GERD do not find relief with first-line therapies. In these patients, it is important to determine compliance with PPIs and that they are being taken at the right time in relation to meals. Unless alarm symptoms are present, patients should not be considered a non-responder to PPI therapy until after 8 weeks of therapy. Investigations for non-

responders include upper GI endoscopy, pH testing and pH-impedance testing. pH testing should be done while the patient is off PPIs to determine whether there is persistent acidic or nonacidic reflux. If pH and pH-impedance tests are normal, the most common causes of continuing symptoms are reflux hypersensitivity and functional heart burn. Reflux hypersensitivity is a heightened response to nonpathologic reflux, while functional heartburn is the presence of symptoms without any evidence of abnormal exposure.

These patients should be reassured that their condition is benign and they may be treated with a pain modulator, such as a selective serotonin reuptake inhibitor or tricyclic antidepressant.

PPIs should be discontinued in patients who do not respond to them. p6m In patients with non-acid reflux, a trial of baclofen should be offered, as it reduces the rate of transient LES relaxations.

4. Surgery and endoscopic procedures Antireflux surgery should be recommended with caution, as it can have severe side effects, including dysphagia, gas bloat syndrome and flatulence. The intended effect may only be temporary and up to 60% of patients will require antireflux medications regularly in the decade afterward.

Endoscopic transoral incisionless fundoplication (TIF) may help to control symptoms in approximately two thirds of patients. In clinical studies, TIF showed better symptomatic control than PPIs (67% vs. 45% of patients), and reduced oesophageal acid exposure time from 9.3% to 6.4%. Meta-analysis showed that, compared to the Nissen procedure and PPIs, TIF was associated with better improvement in quality of life.

REFERENCE Young A, Kumar MA, Thota PN. GERD: A practical approach. Cleveland Clinic Journal of Medicine 2020;87(4):223-230.

RESOLVE THE REFLUX Choose...

TOPZOLE®: SOUTH AFRICA’S NO.1 PPI PANTOPRAZOLE*1 • Effective GORD symptom relief2 • Daily pantoprazole maintenance therapy for severe acid-peptic disease is effective and well tolerated for up to 15 years3 • Low potential for drug interactions4 • TOPZOLE® 20 mg is suitable for on-demand use, once daily, when required5 DOSAGE Duodenal ulcer

OD for 2-4 weeks

Gastric ulcer

OD for 4-8 weeks

Reflux oesophagitis

OD for 4-8 weeks

DOSAGE Mild GORD

OD for 4 weeks. May be repeated for another 4 weeks if complete healing has not been achieved within the first 4 weeks

Long-term management and prevention of relapse of GORD

20 mg OD. May be increased to 40 mg OD should relapse occur, to be reduced to 20 mg OD once healing of relapse has been achieved

*in relation to sales value; GORD = Gastro-oesophageal reflux disease; OD = Once daily; PPI = Proton pump inhibitor References: 1. IMS Data, MAT Value 01/2021. 2. Scholten T, Gatz G, Hole U. Once-daily pantoprazole 40 mg and esomeprazole 40 mg have equivalent overall efficacy in relieving GERD-related symptoms.

Aliment Pharmacol Ther. 2003;18:587-594. 3. Brunner G, Athmann C, Scheider A. Long-term,open-label trial: safety and efficacy of continuous maintenance treatment with pantoprazole for up to 15 years in severe acid-peptic disease. Aliment Pharmacol Ther. 2012;doi:10.1111/j.1365-2036. 2012.05106.x:1-11. 4. Blume H, Donath F, Warnke A, Schug BS. Pharmacokinetic Drug Interaction Profiles of Proton Pump Inhibitors. Drug Safety. 2006;29(9):769-784. 5. Topzole Approved Package Insert. Takeda (Pty) Ltd. 2012 September 14.

S4 TOPZOLE® 20. Reg. No. 38/11.4.3/0061. Each enteric-coated tablet contains 20 mg pantoprazole. S4 TOPZOLE® 40. Reg. No. 38/11.4.3/0060. Each enteric-coated tablet contains 40 mg pantoprazole. For full prescribing information, refer to the Professional Information approved by the Medicines Regulatory Authority.

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GASTROENTEROLOGY Focus CLINICAL GASTROENTEROLOGY

PPIS VS PRIMARY REFLUX SURGERY What is the recurrence rate of gastro-oesophageal reflux after primary laparoscopic antireflux surgery?

In a retrospective cohort study of 2 655 patients who underwent primary laparoscopic antireflux surgery for gastro-oesophageal reflux disease (GORD or GERD) in 2005-2014, reflux recurrence occurred in 17% (83% requiring long-term treatment with proton pump inhibitors or histamine2 receptor antagonists,

16% undergoing secondary antireflux surgery).

Risk factors for recurrence were older age, female sex, and comorbidity. Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment, diminishing some of the benefi ts of the operation.

Recurrence of GORD is relatively common among patients who have laparoscopic antireflux surgery, potentially diminishing some of the surgery's benefi ts, suggests a retrospective study in JAMA. The 30-day complication rate after the primary surgery was 4%.

An editorialist speculates that ‘young and otherwise healthy men’

Help your patients CONqUER heartburn when they need a little more!*1,2

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Antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment

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Omeprazole is the most prescribed PPI molecule,6 suitable for patients that: •

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• have a repeat prescription that has expired2,4 •

require 24-hour relief with convenient once-a-day dosing2,5

With ADCO OMEPRAZOLE 20 and RAPACID (omeprazole 10 mg), you can offer your patients effective and affordable PPI therapy, without a prescription.1-3,5-7 PPI – proton pump inhibitor; OTC – over-the-counter *If symptom control has not been achieved after 2 weeks of treatment with 20 mg (one capsule) daily, further investigation is recommended.

References: 1. Bate CM, Booth SN, Crowe JP, et al. Omeprazole 10 mg or 20 mg once daily in the prevention of recurrence of reflux oesophagitis. Gut 1995;36:492-498. 2. ADCO OMEPRAZOLE 20 capsules Approved Package Insert, 23 July 2004. 3. RAPACID Capsules Approved Package Insert, 09 December 2008. 4. National Institute for Health and Care Excellence (NICE) Clinical Guideline CG184 Gastrooesophageal reflux disease and dyspepsia in adults: investigation and management. September 2014. Available at www.nice.org.uk/guidance/cg184. Last Accessed May 2021. 5. Armstrong D, Nakhla N. Non-prescription proton-pump inhibitors for self-treating frequent heartburn: the role of the Canadian pharmacist. Pharmacy Practice 2016;14(4):868. 6. TPM MAT/03/2021. A2/B2 (Proton Pump Inhibitors oral units) Market. 7. Generics Dictionary. [online] Available at: http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_name_eq%5D=OMEPRAZOLE&q%5Bmanufacturer_ name_cont%5D=&q%5Bbrand_cont%5D= [Accessed 27 May 2021].

S2 RapAcid capsule. Each capsule contains 10 mg omeprazole. Reg. No.: A39/11.4.3/0466. S2 Adco Omeprazole 20 capsule. Each capsule contains 20 mg omeprazole. Reg. No.: 37/11.4.3/0228.

For full prescribing information, please refer to the professional information approved by SAHPRA (South African Health Products Regulatory Authority).

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might find laparoscopic antireflux surgery to be appealing, as they seem to have the lowest rate of GORD recurrence after antireflux surgery and otherwise would likely require decades of PPI treatment without the operation’.

In a related editorial, Dr Stuart Spechler, from the Center for Esophageal Diseases at Baylor University Medical Center, Dallas, noted that with only two established options available to treat recurrent GORD. clinicians must thoroughly discuss the risks and benefi ts of treatment with their patients.

“There are wide variations among individuals in how they perceive and deal with different risks, and those factors should play a major role in guiding management choices,” he said.

Source: JAMA

16422 Adco-Omeprazole 160wx225h.indd 1

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CLINICAL | GASTROENTEROLOGY

GASTROENTEROLOGY Focus

Biopsies not needed for majority of childhood coeliac diagnoses say experts

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has issued new guidance to physicians on the diagnosis of coeliac disease in children recommending the no-biopsy approach at diagnosis for the majority of children suspected of having the disease1.

C

URRENTLY, AROUND HALF of children with suspected coeliac disease undergo a biopsy to confirm their diagnosis but rather than invasive and distressing endoscopy, experts are now recommending that children undergo a twostage blood test to establish a diagnosis of coeliac disease that would mean the majority who currently have one, would no longer require a biopsy1.

The new advice for clinicians comes as an update to the 2012 guidance2 published by the Society brings the original guidelines up-to-date; providing an evidenced-based guideline that, wherever possible, enables accurate serology-based diagnosis without the need for biopsy.

The new guidance, published in the Journal of Pediatric Gastroenterology and Nutrition, could save millions of euros in direct healthcare costs each year as biopsies on children, and the required general anaesthetic to perform them, cost around €1,000 per patient3.

The new guidelines recommend that: • Testing for specific antibodiesii should be 28 Dec '20/Jan '21 | MEDICAL CHRONICLE

performed as initial screening in children with suspected coeliac disease • Asymptomatic children can be diagnosed without the need for a biopsy, using the same criteria as in patients with symptoms • The decision on whether to perform a diagnostic biopsy should be made as a shared decision between clinicians and parents, and where appropriate, with the child too.

Coeliac disease affects one in every 100 children4 in the majority of European countries and, in some countries, it can occur as frequently as three in every 100. It is a lifelong autoimmune condition, caused by an abnormal reaction to gluten – a protein found in wheat, barley and rye – grains that are very common in the European diet. It can occur at any age, including in babies when weaning once gluten has been introduced to their diet, in children and in adolescence.

Currently, the only treatment for coeliac disease is strict compliance to a gluten-free diet. Coeliac disease is the most common food-related chronic disease among children

in Europe, yet experts now believe that up to 80% of cases are undiagnosed5. With rising prevalence, undiagnosed coeliac disease leaves a large population at risk of nutritional and developmental problems and long-term associated health complications. Despite being easy to detect and treat, diagnostic delays can often reach 10-13 years from the first symptoms6. The new guidelines are therefore aimed at making diagnosis as easy and accurate as possible, to help enable earlier diagnosis and higher detection rates.

Commenting, Luisa Mearin, secretary of the Coeliac Disease Working Group and senior author of the new guidelines said: These new guidelines mean that more than half of all children being investigated for coeliac disease will no longer need to have an invasive biopsy. This is a big step forward in our mission to ensure that children can be diagnosed and effectively treated for coeliac disease. It is scandalous that so many children go so long, often up to 10 years, without diagnosis. Removing the need for biopsy in order to achieve diagnosis will reduce the stresses associated with such an invasive procedure and mean that

diagnoses are quicker and cheaper for healthcare systems.”

ESPGHAN has also published an abridged, patient-friendly guide, which is available here: https://espghan.info/ advice-guides/ REFERENCES: 1. Husby, Steffen, et al. "European society paediatric gastroenterology, hepatology and nutrition guidelines for diagnosing coeliac disease 2020." Journal of Pediatric Gastroenterology and Nutrition 70.1 (2020): 141-156.

2. Husby, S., et al. "European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease." Journal of Pediatric Gastroenterology and Nutrition 54.1 (2012): 136-160.

3. BSPGHAN/Coeliac UK (2013). Biggest shake up in diagnostic practice for coeliac disease in 40 years will aid diagnosis in children, get quicker treatment and may bring savings for the NHS. [Press Release] 20 February.

4. Mustalahti, Kirsi, et al. "The prevalence of celiac disease in Europe: results of a centralized, international mass screening project." Annals of medicine 42.8 (2010): 587-595.

5. Ivarsson, Anneli, et al. "High prevalence of undiagnosed coeliac disease in adults: a Swedish population-based study." Journal of internal medicine 245.1 (1999): 63-68.

6. Violato, Mara, and Alastair Gray. "The impact of diagnosis on health-related quality of life in people with coeliac disease: a UK popu

GASTROENTEROLOGY Focus CLINICAL | GASTROENTEROLOGY

Key facts

about probiotics and antibiotics The gut microbiome is a complex ecosystem of trillions of microbes that live together in harmony in the gastrointestinal tract.

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HESE MICROBES HAVE an impact on human health, aiding digestion, immunity, skin health and energy.

A balance is required between beneficial

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A well balanced gut flora consists of trillions of micro-organisms most of which are bacteria in our digestive tract working together to keep our body and mind healthy.1,2 There are many probiotic supplements but only one PROBIFLORA. References: 1. Role of the gut microbiota in nutrition and health. BMJ 361:Supp1. :36 - 44. (28 April 2019) Available from:http://www.bmj.com/ 2. Kho, Z.Y. and Lal, S.K. The Human Gut Microbiome – A Potential Controller of Wellness and Disease. Front. Microbiol, 2018. 9(1835):1-23.

Probiflora Junior Everyday Flora Balance. Each tablet contains total probiotics 1 billion cfu (colony forming units), probiotic blend consisting of Lactobacillus helveticus R-52ME, Lactobacillus rhamnosus R-11ME, Bifidobacterium longum R-175M. Health supplement. This unregistered medicine has not been evaluated by the South African Health Products Regulatory Authority for quality, safety or intended use.

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8 MEDICAL CHRONICLE 12 NOVEMBER 2020 | MEDICAL CHRONICLE

essentially non-selective and can also deplete the beneficial bacteria residing in the gut. This is thought to contribute to the development of diarrhoea, constipation and/ or vaginal thrush when taking an antibiotic.

In certain cases, this disruption to the gut microbiome can result in an overgrowth of unwanted, pathogenic bacteria such as Clostridium difficile.

KEY FACTS • Antibiotics deplete the populations of natural friendly bacteria that live in our gut, known as the gut microbiome.

This may result in side effects such as diarrhoea, nausea, indigestion and low energy. Taking a live culture supplement alongside antibiotics may help to reduce the risk of certain common antibiotic side effects • Rather than waiting until after the antibiotic course, it's best to take a probiotic supplement that has been designed to take alongside antibiotics, to help maintain balance in the gut microbiome • Antibiotic resistance is becoming increasingly common, exacerbated by patients not completing antibiotic courses. Taking probiotics with antibiotics may help to maintain gut health thereby reducing the risk of side effects and enabling individuals to complete the full course of antibiotics • Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 are two probiotic strains shown to reach the gut alive even when taken at exactly the same time as antibiotics • The best time to take the probiotic Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 is at breakfast time, regardless of when the antibiotic is recommended to be taken • If taking other probiotic strains with antibiotics, advice is dependent on the supplier but standard recommendation is to wait at least two hours after your antibiotics before taking probiotics • It is best to select strains that have been extensively researched alongside antibiotics.

PROBIOTICS IN CHILDREN Children aged one year and over can also take Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11, which have been trialled in this young age group. However, parents may wish to seek a supplement especially formulated for children’s gut health.

References available on request.

GASTROENTEROLOGY Focus

Novel treatment for ulcerative colitis

Dr Barney Hawthorne, a consultant gastroenterologist at the University Hospital of Wales in the UK, reviewed the Multimatrix System (MMX) mesalazine in the management of ulcerative colitis.

M

MX MESALAZINE IS a new formulation of 5-aminosalicylic acid (5-ASA) – a novel 5-ASA delivery tablet that starts to release the drug in the terminal ileum and caecum, and then allows the slow release of this drug during passage through the colon. An ideal drug delivery system it does not release the drug at all in the upper small bowel but starts to release the drug gradually in the ileocaecal region, and then progressively throughout the colon.

The delayed-release mesalazine formulation has a high-strength 1.2g tablet for the treatment of active mild to moderate colitis and maintenance of remission. In vitro and in vivo studies show initiation of drug release in the terminal ileum and caecum with gradual release of 5-ASA as the tablet passes through the colon.

Mesalazine or 5-ASA remains the first-line therapy for treatment of mild to moderately active ulcerative colitis, and maintenance of mucosal healing. The drug exerts a topical anti-inflammatory effect on colonic mucosa.

In mild and moderate colitis, the product shows high rates of remission and mucosal healing in clinical trials with stringent endpoints. Once-daily dosing is as effective as divided doses, and the 2.4g dose appears as effective as 4.8g daily.

It is becoming clear that once daily therapy is effective for other formulations of 5-ASA, and this benefit is not exclusive to MMX mesalazine. Other considerations, particularly cost and patient preference, must be taken into consideration in choosing a formulation for individual patients, but there is no doubt that this drug is a welcome addition to the therapeutic armamentarium.

The left colon in normal patients, and certainly in active colitis, is generally relatively empty, and represents a much more challenging area for drug delivery. This study showed that oral MMX mesalazine is as effective as enemas in left-sided disease, confirming delivery of the drug in significant amounts to the left colon.

Pharmacokinetic data are comparable to other 5-ASA formulations with low systemic absorption and high levels in faeces and in mucosal biopsies in the left colon. Clinical trials have shown high rates of clinical and endoscopic remission in active mild to moderate colitis over eight weeks with a 2.4g once-daily dose. There do not appear to be higher remission rates with the 4.8g dose. Prolongation of treatment with a further eight weeks of 2.4g twice daily can induce remission in those failing the initial eight weeks of therapy.

A maintenance study enrolling patients who achieved remission in the acute

studies showed high rates of remission maintained at one year with 1.2g twice daily (68%) and 2.4g once daily (64%) using the strict definition of remission (including mucosal healing) that was used

in the active treatment trials. The drug is safe and effective in colitis. The high tablet strength, and once-daily dosage make this formulation a welcome addition to therapy options for patients with colitis.

REFERENCE Hawthorne AB. A Review of Multimatrix System (MMX) Mesalazine in the Management of Ulcerative Colitis. Clinical Medicine Therapeutics. 2009. doi:10.4137/CMT.S38

Prolonged release mesalazine for patients with mild-to-moderate ulcerative colitis1,2

2

Mezavant® is a valuable option in the management of patients with mild to moderate ulcerative colitis1

MMX® TECHNOLOGY FOR PROLONGED DRUG RELEASE2-5

DELIVERS MESALAZINE (5-ASA) THROUGHOUT THE COLON2-5

ALWAYS ONCE DAILY2

HIGH-DOSE FORMULATION REDUCES THE DAILY TABLET BURDEN1

IMPROVED ADHERENCE TO TREATMENT6

MEZAVANT IS INDICATED FOR:2 The treatment and maintenance of remission in ulcerative colitis The approved Mezavant professional information should be consulted before prescribing.

5-ASA: 5-acetyl salicylic acid References: 1. Yang LPH, McCormack PL. MMX® Mesalazine: A review of its use in the management of mild to moderate ulcerative colitis. Drugs 2011;71(2):221-235. 2. Mezavant approved package insert, August 2013. 3. Brunner M, Assandri R, Kletter K, Tschurlovits M, Corrado Me, Villa R, et al. Gastrointestinal transit and 5-ASA release from a new mesalazine extended-release formulation. Aliment Pharmacol Ther.

2003;17:395–402. 4. Tenjarla S, Romasanta V, Zeijdner E, Villa R, Moro L. Release of 5-aminosalicylate from an MMX mesalamine tablet during transit through a simulated gastrointestinal tract system. Advances in Therapy 2007;24(4):826-840. 5. Tenjarla S, Abinusawa A. In-vitro characterization of 5-aminosalicylic acid release from MMX mesalamine tablets and determination of tablet coating thickness. Adv Ther 2011;28(1):6272. 6. Simoni SE, Felipsen SF, Conegero Sanches AC, Vasconcelos HL. Multi-Matrix 5-Aminosalicylic Acid Efficacy in Induction of Remission in Mild-to-Moderate Ulcerative Colitis: A Systematic Review. International Journal of Health Sciences, September 2019;7(3): 42-51.

Mezavant® (enteric coated, prolonged release tablet.) Each tablet contains mesalazine 1 200 mg. Reg. No. 45/11/0463. For full prescribing information refer to the professional information approved by the medicines regulatory authority.

To report an Adverse Event, e-mail Adcock.AEReports@adcock.com or call 011 635 0134 To request a copy of the current approved professional information or references, e-mail:Helpdesk.MedicalAffairs@adcock.com ©2019 Shire. All rights reserved. SHIRE and the Shire logo are registered trademarks of Shire Pharmaceutical Holdings Ireland or its affiliates Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa.

Telephone + 27 11 635 0000. www.adcock.com. 16538J. 202102241089543. C-APROM/ZA/MEZ/0003.

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MEDICAL CHRONICLE 9

CLINICAL GASTROENTEROLOGY Focus

GASTROENTEROLOGY

TREATMENT FOR

HEARTBURN

In most cases, heartburn can be relieved through diet, lifestyle changes and occasional over-the-counter (OTC) medication.

In severe cases, treatments include scheduled medicines or even surgery, where gastro-oesophageal reflux disease (GORD) does not respond to medicine.

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treatment for heartburn and a glance at the vast range of options is an indication of the prevalence of symptoms among the general population. Antacids work by neutralising stomach acid to help relieve heartburn.

(They are also11:08 occasionally P.pdf 1 2021/04/08 AM

recommended to help relieve the pain of ulcers, which can also cause heartburn.)

Some antacids also contain simethicone, an ingredient that helps eliminate excess gas. Some antacids contain ingredients that can cause

diarrhoea, such as magnesium, or constipation, such as aluminium.

Antacids must be used exactly as directed by the package label. If in tablet form, patients should chew them well before swallowing for faster relief.

But patients should be advised of side-effects that can occur with overuse of antacids, including constipation, diarrhoea, changes in the colour of bowel movements, and stomach cramps.

When heartburn is caused by GORD, the most effective treatment is a proton pump inhibitor (PPI). Two versions, pantoprazole and lansoprozole, are sold in packs of sevens or 14s, dosed once daily. Patients taking PPIs should not to take them at the same time as the antacids, to prevent interaction.

HEART ATTACK OR HEARTBURN?

Heartburn’s close proximity to the heart means that either one can cause chest pain, which is why many people mistake heart burn for angina and vice versa.

Also, angina can feel like indigestion, which often results in heartburn, so it’s easy to confuse the two. Usually, if a belch doesn’t ease it, or if it is accompanied by shortness of breath or sweating, it may be a heart-related issue. If there is any doubt at all, the patient should consult a doctor urgently.

CLUES THAT HEARTBURN MAY BE GORD • GORD symptoms have been treated with OTC medicines for more than two weeks • Pattern of heartburn has changed it is more frequent or severe • Patients wake up at night with heartburn • Occasionally, heartburn is associated with difficulty swallowing • Heartburn symptoms continue even after taking non-prescription medication • There is hoarseness or worsening of asthma after meals, lying down, or exercise, or asthma that occurs mainly at night • Unexplained weight loss / loss of appetite • Heartburn symptoms interfere with lifestyle or daily activity • Increasing doses of non-prescription medicine are needed to control heartburn.

References available on request.

18099 Gaviscon 2015 CHRONICLE - AcidPocket(A4Advert).indd 1 10 MEDICAL 44 AUGUST 2017 | MEDICAL CHRONICLE

1/29/15 12:01 PM

CLINICAL | GASTROENTEROLOGY

GASTROENTEROLOGY Focus

South Africans

should prioritise gut health The One Health Summit themed Your Gut’s Instinct took place on 27 August 2020. The event, hosted in webinar format given the current Covid-19 context, was attended by 500 healthcare professionals and key opinion leaders.

"W

WO RENOWNED INTERNATIONAL experts and South Africa’s own Mpho Tshukudu, a registered dietitian with a special interest in South Africa’s food culture and heritage, shared developing science on the topic of gut health, and applied relevance for the South African context, considering local beliefs, behaviours and dietary practices.

Prof Rob Knight, the founding director of the Centre for Microbiome Innovation in California explored the emerging science of the gut microbiome as a gateway to overall health and described the gut and its microbiome as ‘the new factors impacting your whole lifespan and health outcomes’.

According to Prof Knight, the microbiome can be a predictor and influencer of traits and outcomes for health and disease. In fact, some traits are better explained by the microbiome (with up to 90% accuracy for obesity), than the host genome (with up to 60% accuracy). A review conducted by Montiel-Castro et al (2013), summarised evidence of several health conditions which may be affected by intestinal microbiota, including pain, autism, obesity, cardiovascular risk, anxiety, depression and multiple sclerosis.

Maintaining equilibrium in the gut is protective against disease, however, modern life stressors can influence the gut microbiome negatively. Evidence has shown that modern lifestyles have resulted in the disappearance of large groups of microbes, lending towards gut dysbiosis.

Lifestyle factors strongly influence the structure, diversity, and composition of the microbiome, and diet can have a large effect, even compared to the impact of disease and drug intervention. According to Prof Knight, “We can reshape the gut microbiome with nutrition.” In particular, the intake of fruits and vegetables rich in fibre and phytonutrients, and fermented foods may have a positive effect.

Andrea Hardy, a registered dietitian and known as ‘Canada’s gut health expert’ explored the role of nutrition in influencing gut health. According to Hardy, “Nutrition

32 OCTOBER 2020 | MEDICAL CHRONICLE

is the quickest and easiest way to influence our gut microbiota.” A Western diet characterised by a high intake of sugar and fat, red and processed meats consumed in excess and low intake of dietary fibre is associated with depletion of microbial diversity and abundance, impaired growth and function of the mucous layer affecting gut permeability and low-grade chronic inflammation. Conversely, a diet focused on adequate fibre and variety, with intake of phytochemicals, omega-3 fats, probiotics, prebiotics and fermented foods is associated with microbial diversity and abundance, enhanced function of the mucous layer and decreased inflammation.

The latter dietary approach promotes production of short chain fatty acids, which help maintain the gut microbiota, the gut barrier function, and overall gut health.

Hardy elaborated on the role of probiotics delivered through foods and described them as a ‘win-win’ in which patients can obtain nutrients and beneficial bacterial cultures in a manner that is simple and easily adopted into most patients’ lifestyles. The International Scientific Association for Probiotics and Prebiotics (ISAPP) and the International Probiotics Association (IPA) have developed the following four criteria to define probiotics: the probiotic must be sufficiently characterised, be safe for intended use, be alive in sufficient numbers in the product at an efficacious dose throughout shelf life and be supported by at least one positive human clinical trial conducted according to generally accepted scientific standards.

Hardy cautioned that these factors should be investigated to ensure the efficacy of probiotic-containing foods, and illustrated with an example of a yoghurt containing a blend of five cultures including the bacterial strain Bifidobacterium lactis CNCM I-2494, which has been shown in clinical trials to reduce digestive discomfort.

Some evidence indicates that this effect may be associated with an improvement in the objective markers of abdominal distension (bloating) and

decreased transit time. Tshukudu shared unique insights into the cultural and dietary factors affecting gut health among South Africans and lobbied a call to action to all healthcare professionals to ‘better understand all the layers influencing an individual’s food choices and behaviours, in order to deliver relevant, meaningful advice’.

Although data exploring gut health explicitly in South Africa is limited, the insights gained from the study of the nutrition transition (showing an increase in the intake of total energy, added sugar, sodium and ultra-processed foods associated with urbanisation), suggests that digestive wellbeing is neglected. Among South African women, initial interventions in response to digestive discomfort include the use of laxatives, herbal preparations and enemas. These interventions are not recommended as a first line approach and may perpetuate gut health disorders if used long-term. Lifestyle approaches, including dietary intervention, are the preferred first line defence, minimising the need for extreme measures to achieve digestive comfort. According to Tshukudu, in the modern circumstances, some South Africans believe that rural, traditional foods have no role in a modern, healthy diet, and these traditional foods often carry negative connotations of being ‘poverty foods’, despite their valuable nutrient credentials.

Tshukudu recommends integrating South Africa’s traditional food culture with modern application for advice that appeals both to heritage and health trends.

For example: • Encourage the use of prebiotics like onion, ginger and garlic, as well as spices such as black pepper, cayenne pepper, cinnamon, oregano, rosemary and turmeric for the flavouring of foods. Through acculturation, these flavours have been adopted into South African cuisine over time, and positively impact the microbiome18 • Sprouting, soaking and fermenting of grains, lentils, beans and vegetables has been shown to reduce phytates, improve

digestion and decrease flatulence and intestinal discomfort associated with the introduction of beans and legumes.

Encourage these methods of preparation, which are culturally acceptable and carry a modern appeal popularised in the media • Encourage the intake of fruits which offer a source of polyphenols to support gut health. Fruits such as pomegranates, figs, blackberries and baobab grow in rural areas, and evoke positive childhood memories. Recommend these fruits with modern application in smoothies, baking and dressings • Encourage the intake of vegetables, particularly traditional leaves, of which South Africa has over 60 varieties. Morogo for example, is rich in nutrients and fibre.

Use these in modernised recipes, like making pesto, salads and smoothies • Advocate for the intake of legumes and nuts as easily accessible plant proteins. In South Africa, meat consumption is high at the expense of vegetables, nuts and legumes, partly driven by the high status afforded to meat, while plant proteins are considered poverty foods. Leverage the benefits and modern appeal of the flexitarian diet to help improve the value associated with nuts and legumes as protein sources • The ‘sour’ taste associated with fermented dairy foods is a South African taste preference, however due to the high prevalence of lactose intolerance, many South Africans carry hesitation regarding dairy foods.

Educate patients regarding fermented dairy foods, in which a portion of the lactose is digested by the intrinsic cultures in the fermented dairy products, improving tolerance in lactose intolerant individuals. Yoghurt offers a modern appeal to traditional fermented milk.

Choosing a yoghurt containing a blend of strains, including a particular strain of bifidus bacteria, helps to promote digestive comfort and wellbeing when consumed daily.

MEDICAL CHRONICLE 11

GASTROENTEROLOGY Focus CLINICAL | GASTROENTEROLOGY

The microbiomeobesity link

Factors that influence the formation of the gut microbiome during infancy and childhood may have a significant impact on development of obesity and metabolic dysfunction, with life-long consequences.

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and metabolic disease. Mohammadkhah et al recently examined the determinants of gut microbiome composition during infancy and childhood and evaluated 1 2021/04/13 9:56 AM the potential

impact on obesity and cardiometabolic risk.

“The gut microbiome expands rapidly in infants following birth and dysbiosis in infancy or childhood may affect the long-

September 2020 is Childhood Obesity Awareness Month

term health of the gut microbiome,” the authors stated.

PRE-AND PROBIOTIC SUPPLEMENTATION The specific composition of different types of infant formula may modulate the microbiome. Several trials have assessed the inclusion of probiotics or prebiotics such as oligosaccharides in formula to more closely mimic breast milk composition.

Infant formula supplementedwith several Bifidobacterium strains altered microbiome composition in infants, but did not affect long-term colonisation. Current data suggest that inclusion of pre- and probiotics in formula is well-tolerated.

EFFECT OF ANTIBIOTICS According to the authors, frequent use of antibiotics during childhood is associated with increased risk of antibiotic resistance and may predispose them to increased risk of disease, including overweight and obesity, and inflammatory diseases, potentially through modulation of the microbiome. Due to the important role the gut microbiome plays in the development of the immune system, it has been hypothesized that the gut flora may influence the host response to vaccines.

To date, associations between an altered gut microbiome composition and metabolic disorders such as obesity have been suggested. Such links can be through direct (via metabolites) and indirect pathways (via the immune system). “The gut microbiota plays multiple critical roles in the maintenance of their host health, including helping host nutrition and energy harvest, intestinal epithelial homeostasis, drug metabolism and toxicity, immune system response, and protection from pathogens,” they stated.

Help them develop guts like a grown up #Junior #Growhealthy #childhoodobesityawareness A well balanced gut flora consists of trillions of micro-organisms most of which are bacteria in our digestive tract working together to keep our body and mind healthy.1,2 There are many probiotic supplements but only one PROBIFLORA. References: 1. Role of the gut microbiota in nutrition and health. BMJ 361:Supp1. :36 - 44. (28 April 2019) Available from:http://www.bmj.com/ 2. Kho, Z.Y. and Lal, S.K. The Human Gut Microbiome – A Potential Controller of Wellness and Disease. Front. Microbiol, 2018. 9(1835):1-23.

Probiflora Junior Everyday Flora Balance. Each tablet contains total probiotics 1 billion cfu (colony forming units), probiotic blend consisting of Lactobacillus helveticus R-52ME, Lactobacillus rhamnosus R-11ME, Bi idobacterium longum R-175M. Health supplement. This unregistered medicine has not been evaluated by the South African Health Products Regulatory Authority for quality, safety or intended use.

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12 MEDICAL CHRONICLE 28 SEPTEMBER 2020 | MEDICAL CHRONICLE

CONCLUSIONS There is considerable evidence linking gut microbiome composition to cardiometabolic disease pathophysiology.

Strategies that target specific bacteria or functional pathways may show promising results but remain to be tested in appropriate human trials.

REFERENCES Mohammadkhah A et al. Development of the Gut Microbiome in Children, and Lifetime Implications for Obesity and Cardiometabolic Disease Children 2018, 5, 160; doi:10.3390.

Kazemian et al. Gut microbiota and cardiovascular disease: opportunities and challenges Microbiome (2020) 8:36. https://doi.org/10.1186/s40168020-00821-0

CLINICAL | GASTROENTEROLOGY

GASTROENTEROLOGY Focus

What role does the microbiome play in developing allergies?

The significant increase in the prevalence of allergic diseases reported over the last few years has closely paralleled substantial environmental changes both on a macro and micro scale, which have led to reduced microbial exposure in early life and perturbation of the human microbiome composition.

I

NCREASING EVIDENCE SHOWS that early life interactions between the human microbiome and the immune cells play a pivotal role in the development of the immune system. The process of early colonisation by a healthy microbiome is emerging as a key determinant of life-long health. The disruption of this process results in changes in the hostmicrobiome biodiversity and metabolic activities. This has been associated with greater susceptibility to immunemediated disorders later in life, including allergic diseases.

Over the last few decades, many developed and emerging countries have shown a dramatic increase in the prevalence of asthma, AD and food allergies, which currently pose a substantial burden to healthcare systems.

According to Peroni et al (2020), this allergy epidemic is linked to radical environmental and lifestyle changes, such as industrialisation and urbanisation, widespread sanitation programmes and antibiotics use, physical inactivity and highly processed diets. All these changes have led to reduced microbial exposure in early life and loss of microbial biodiversity.

Accumulating evidence shows the role of the human microbiome in combatting the rising prevalence of allergic diseases.

“The human microbiome comprises

bacteria, viruses, fungi, protozoans, and archaea, which colonise primarily the gastrointestinal tract, but also the airways and the skin surface from the first days of life and gradually develop and diversify concomitantly with the physiological growth of the individual. The resident microbial communities in the human gut and other organs have been shown to modulate both the innate and acquired immune responses. Recent data show that several environmental drivers can affect the microbiome colonisation, composition and metabolic activity in infancy, and alter the host functions for nutrition and immunity.”

The process of early colonisation by a healthy microbiome is emerging as a key factor in life-long health, whereas the disruption of this process has been associated with greater susceptibility to immune-mediated disorders later in life, including allergic diseases.

“It is well established that microbiome composition changes dynamically in the first few years of life and can be influenced by several prenatal and postnatal environmental and host-related factors.

Among these factors, mounting evidence shows that some perinatal factors, such as mode of delivery, breastfeeding, early antibiotic use, and timing and type of complementary feeding, can significantly modulate the gut microbiome composition,

36 SEPTEMBER 2020 | MEDICAL CHRONICLE

which is emerging as a key determinant in developing immune tolerance responses to different antigens,” the authors said.

The first 1000 days of life, which is the period from conception to two years of age seem to represent the critical window of opportunity for microbiome modulation.

After this period, the gut microbiome becomes more adult-like with distinct microbial community composition and functions. However, several factors can disturb the gut microbiome composition later in life, such as long-term dietary changes, or frequent or prolonged use of antibiotics.

Diet is a key factor in preventing the onset of allergies. Breastfeeding increases the colonisation by some beneficial bacteria such as Lactobacilli and Bifidobacteria.

Breast milk contains oligosaccharides, a type of complex carbohydrates, which are the main food for gut microbiota and that contribute to have a balanced bacterial community able to train the immune system. After the weening, the composition of gut microbiota in babies becomes more diverse.

Exposure to antibiotics has been demonstrated to be one major causes of gut microbiota imbalances. These imbalances are linked to diverse health problems.

Emerging evidence shows that gut microbial disturbances in early life can also

influence the development of allergic airway inflammation, such as asthma. Preclinical models support a protective role of bacteria against allergic airway inflammation.

CONCLUSION Early life is a crucial period for microbiome and immune development. The perturbation of the development and maturation of the microbiome during the first few years of life can have a variety of harmful effects on immune health, contributing to determining the development of atopic diseases. Although current understanding of the relationships between early life nutrition, microbiome, and immune system development has significantly increased in recent years, substantial knowledge gaps persist regarding the molecular mechanisms involved. Understanding these mechanisms is of the outermost importance to develop effective prevention strategies for allergic diseases.

REFERENCES Peroni et al. Microbiome Composition and Its Impact on the Development of Allergic Diseases. Front Immunol.

2020; doi: 10.3389/fimmu.2020.00700.

European Society for Neurogastroenterology and Motility

MEDICAL CHRONICLE 13

GASTROENTEROLOGY Focus PAEDIATRIC GASTROENTEROLOGY

IBS: MORE THAN A SIMPLE IRRITATION

The irritable bowel syndrome (IBS) is a chronic and sometimes disabling functional bowel disorder.

Emerging evidence suggests that distinct pathophysiological disturbances may account for the symptoms and that IBS is unlikely to be one disease or merely a psychiatric (somatosensory) disorder.

The Rome IV criteria constitute Scopex A4 Advert 0421 V5 P.pdf the current standard for diagnosing

IBS. According to these criteria, IBS is diagnosed on the basis of recurrent abdominal pain related to defecation or in association with a change in stool frequency or form. Bloating is a common accompanying symptom.

Symptoms must be chronic, occurring at least once per1:59 week, on average, in 1 2021/04/09 PM the previous 3 months, with a duration

of at least 6 months.

Diagnosing IBS accurately, minimising invasive investigations, and recommending effective treatment have an important role in efforts to reduce the societal and economic effects of the disease.

Ordering a panel of blood tests routinely is unsupported by the

evidence, although clinicians often request a complete blood count and C-reactive protein measurement to help rule out inflammatory bowel disease.

CLASSIFICATION On the basis of the Rome IV criteria, IBS is classified into four subtypes (IBS with diarrhoea, IBS with constipation, IBS with mixed symptoms of constipation and diarrhoea, or unsubtyped IBS) according to patients’ reports of the proportion of time they have hard or lumpy stools vs loose or watery stools. The rationale for these subtypes is to improve the homogeneity of patients recruited for clinical trials, guide effective diagnosis and therapy, and increase knowledge of potential pathophysiological mechanisms.

In a patient who has symptoms meeting the Rome IV criteria, with no alarm features, make a positive diagnosis of IBS without resorting to a battery of tests. In patients with IBSlike symptoms dominated by chronic constipation, obstructive defecation (pelvic-floor dyssynergia) should be considered, since the condition responds to biofeedback.

In patients who have IBS with diarrhoea or with both diarrhoea and constipation, distinguishing between organic and functional lower gastrointestinal disease on the basis of symptoms may be more difficult.

In patients with these subtypes of IBS, measurement of the fecal calprotectin level is useful because it can discriminate between IBS and inflammatory bowel disease with good accuracy (i.e., high sensitivity and specificity).

COMPLEMENTARY AND ALTERNATIVE THERAPY Many patients with IBS are dissatisfied with conventional medical therapies and seek other forms of treatment. Any benefit of herbal therapies remains unclear, since few studies have been conducted. St. John’s wort and a combination of plant extracts known as STW5 have both been tested in patients with IBS. STW5 showed superiority over placebo, but St. John’s wort was of no benefit. Melatonin has been reported to reduce abdominal pain in patients with IBS. Reference

Ford A, Lacy B, Talley N. Review article: Irritable Bowel Syndrome. N Engl J Med 2017; 376:2566-2578. DOI: 10.1056/ NEJMra1607547.

14 MEDICAL CHRONICLE 20 MARCH 2018 | MEDICAL CHRONICLE

CLINICAL | GASTROENTEROLOGY GASTROENTEROLOGY Focus

The importance of gut microbiota in early childhood The period from conception to two years of age represents a critical time of early childhood growth and development.

Emerging evidence suggests that the colonisation of microbes in the human body during early life plays a critical role in lifelong growth and development.

T

HIS CAN HAVE an impact on many disease entities. Acute otitis media (AOM) is one of the most common bacterial infections in children.

Cárdenas et al 2019 looked at prevention of recurrent acute otitis media in children using Lactobacillus salivarius PS7, a targetspecific probiotic strain, specifically tailored for its antagonism against otopathogens.

Since L. salivarius PS7 was safe and displayed a strong antimicrobial activity against otopathogens, its efficacy in preventing rAOM was assessed in a trial involving 61 children suffering from rAOM. Children consumed daily ~ 1 x 109 CFU of L. salivarius PS7, and the number of AOM episodes were registered and compared with that observed in the previous six and 12 months. The microbiota of samples collected from the external auditory canal samples was quantitatively and qualitatively assessed.

The number of AOM episodes during the intervention period decreased significantly (84%) when compared to that reported during the six months period before the probiotic intervention. L. salivarius PS7 was found to be a promising strain for the prevention of rAOM in infants and children.

Similarly, Wang et al (2016) systematically reviewed data from randomised controlled trials to investigate the effect of probiotic consumption on RTIs in children. A total of 23 trials involving 6269 children were eligible for inclusion in the systematic review. The results of metaanalysis showed that probiotic consumption significantly decreased the number of subjects having at least 1 RTI episode.

They concluded that probiotic consumption appears to be a feasible way to decrease the incidence of RTIs in children.

Luoto et al (2014) found that gut microbiota modification with specific prebiotics and probiotics might offer a novel and cost-effective means to reduce the risk of rhinovirus infections.

The establishment and interactive development of this early gut microbiota are believed to be (at least partially) driven and modulated by specific compounds present in human milk. It has been shown that certain genomes of infant gut commensals, in particular those of bifidobacterial species, are genetically adapted to use specific glycans of this human secretory fluid.

Milani et al (2017) showed how the development and maturation of gut microbiota constitute a dynamic and non-random process, in which positive and negative interactions between key microbial taxa take place. This process is influenced by various perinatal conditions, such as mode of delivery, type of feeding

quantify in humans. According to Saavedra et al (2004), long-term consumption of formulas supplemented with B. lactis and S. thermophilus was well tolerated and safe and resulted in adequate growth, reduced

and antibiotic usage. Diet, the mother’s age and metabolic status, and family genetics and lifestyle have also been reported to impact the infant microbiota, although these are more difficult to determine and

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reporting of colic or irritability, and a lower frequency of antibiotic use.

Sources: References available on request.

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MEDICAL CHRONICLE MEDICAL CHRONICLE | AUGUST 20201521

GASTROENTEROLOGY Focus CLINICAL | GASTROENTEROLOGY

Poo is taboo

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IBD Africa, headed by gastroenterologist Dr David Epstein, is a recently launched non-profit organisation that hopes to improve inflammatory bowel disease (IBD) care in SA through research, education and advocacy. The organisation held a panel discussion with international IBD expert, Prof Stefan Schreiber, to bring awareness to this condition.

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“There is an exponential increase in new cases of IBD diagnosed each year in Cape Town,” said Dr Epstein, discussing data from five practices in Cape Town, "with the majority of people being diagnosed in their 20s and 30s."

The average age of diagnosis is late 20s for Crohn’s and 35 for ulcerative colitis. However, IBD can be found in patients as young as five, and in others it emerges in old age.

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ROHN’S DISEASE AND ulcerative colitis, collectively known as IBD, is a chronic autoimmune disease affecting the gut. IBD is increasing exponentially in

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References: 1. IMS Market data. May 2020. Data onNEW File. 2. Braun J,approach Kudrin A. Switching to biosimilar infliximab (CT-P13): Evidence of clinical safety, effectiveness and impact on public health. Biologicals 2016;44:257-266. 3. Blair e,erive, ene Irene ExtIrene Ext 30,Ext 30, Pretoria, Ext 30, Pretoria, 30, Pretoria, Pretoria, South South South Africa.

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GUTsi Take QR doi: 10.1186/s13075-016-0981-6. 5. Yoo DH, Prodanovic N, Jaworski J, Miranda P, Ramiterre E, Lanzon A, et al. Efficacy and safety of CT-P13 (biosimilar infliximab) APPLE in patients with rheumatoid arthritis: comparison between EDOCED RQ OCELRPQPEALPPA APPLE APPLE QR APPLE QR CODE QR CODE QR CODE CODE GOOGLE GOOGLE GOOGLE GOOGLE QRQR CODE QR CODE QR CODE CODE According to Sr Karin Davidson, a switching from reference infliximab to CT-P13 and continuing CT-P13 in the PLANETRA extension study. Ann Rheum Dis. 2017;76:355–363. 6. Park W, Yoo DH, Jaworski J, Brzezicki J, Gnylorybov A, Kadinov V, et al. Comparable long-term efficacy, as assessed by patient-reported outcomes, safety and pharmacokinetics, of CT-P13 and reference infliximab in patients with ankylosing spondylitis: 54-week results from the randomized, parallel-group specialist IBD nurse in IBD Africa, “Every PLANETAS Res Ther.

10.1186/s13075-016-0930-4.

7. Park Yoo DH, Miranda sites P, Brzosko M, Wiland P, Gutierrez-Ureña S, et al. Efficacy and safety of switching from reference infliximab to CT-P13 References: 1.

Hardystudy.

JG,Arthritis Harvey WJ,2016;18:25.

Sparrowdoi:RA, et al. Localization ofW,drug release from an oral sustained-release formulation of 5-ASA (Pentasa ) in the gastrointestinal comparedscintigraphy. with maintenance JofClin CT-P13Pharmacol. in ankylosing spondylitis: 102-week data from PLANETAS IR. extension study. Ann Rheumstudy Dis 2017;76:346–354.

8. Goll GL, Jørgensen KK, Sexton J, Olsen IC, Bolstad N, Haavardsholm EA, human gut. and Asacol in the tract using gamma 1993;33:712-718.

2.theWilding A scintigraphic to evaluate what happens to Pentasa et al. Long-term efficacy and safety of biosimilar infliximab (CT-P13) after switching from originator infliximab: open-label extension of the NOR-SWITCH trial. J Intern Med. 2019;285(6):653-669. 9. Gabbani T, Deiana S, Annese patient is unique. This also makes it a Practical Gastroenterology.

Suppl to and November 1999:1-8.

3. Development Rijk MCM,andvan Schaik A,1653–1661.

Van Tongeren JHM. Disposition of mesalazine from mesalazine-delivering drugs in patients with V. CT-P13: design, development, place in therapy.

Drug Design, Therapy 2017:11 inflammatory bowel disease, with and without diarrhoea. Scand J Gastroenterol 1992;27(10):863-868. 4. Christensen LA, Fallingborg J, Abildgaard K, et al. Topical and systemic difficult condition to manage. Every patient availability of 5-aminosalicylate: comparisons of three controlled release preparations in man. Aliment Pharmacol Ther. 1990;4:523-533.

S4 REMSIMA powder for concentrate for solution for infusion. Each vial contains: 100 mg infliximab. Reg. No. 52/30.1/0309. needs to be dealt with individually. Kids For full prescribing information refer to the package insert approved by the medicines regulatory authority. Adcock Ingram Limited. mesalazine.

Reg. No.: 43/11/0014.

PENTASA 1 g Suppositories.

S3 PENTASA SACHETS 2 g. Each sachet contains Reg.2No.g1949/034385/06.

Private Bag X69, Bryanston, 2021. Tel. + 27 S3 11 635 0000. www.adcock.com 202006261041764 Each are ostracised, teachers get angry at child suppository contains 1 g mesalazine. Reg. No.: A40/11/0374. S3 PENTASA 500 mg Tablet. Each tablet contains 500 mg mesalazine.

Reg. No.: 33/11/0088. S3 PENTASA 1 g ENEMA. Each 100 ml rectal suspension contains 1 g mesalazine. Reg. No.: 44/11/0888. leaving class to go to toilet often, and the NAME AND BUSINESS ADDRESS OF THE HOLDER OF THE CERTIFICATE OF REGISTRATION: FERRING (Pty.) Ltd. Route 21 Corporate Park, 6 Regency Drive, Irene Ext 30. Pretoria, South Africa. Tel: +27 12 345 6358 Fax: +27 12 345 1156. www.ferring.co.za. PENTASA, child can’t play sports for same reason.

FERRING, and the FERRING logo are registered trademarks of Ferring B.V. For full prescribing information please refer to the package Nurses such as Sr Davidson meet with insert approved by the medicines regulatory authority. 2020/019 Date of preparation: March 2020. the school and the team to manage the 4,5

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16 MEDICAL CHRONICLE 30 MARCH 2020 | MEDICAL CHRONICLE

2021/02/26 11:03

GASTROENTEROLOGY Focus

CLINICAL

GASTROENTEROLOGY

BOWEL PREP FOR COLONOSCOPY WHAT TO CONSIDER

Colonoscopy accuracy and therapeutic safety depends heavily on the quality of bowel cleansing. All current preparation strategies use a combination of dietary restrictions and laxative agents.

An effective and tolerable bowel preparation is important to secure quality of colonoscopies. It remains unclear if sodium picosulphate with magnesium citrate (SPMC), which is considered a tolerable bowel preparation agent, is also an effective alternative for polyethylene glycol (PEG) and sodium phosphate (NaP). A recent review article by van Lieshout et al (2016) compared effectiveness of SPMC to PEG and NaP through assessment of quality of bowel cleansing measured by validated tools.

The authors searched electronic databases up to January 2015.

Only randomised controlled trials (RCTs) were included. Two authors independently performed selection of studies, risk of bias assessment and data extraction.

Results: Thirteen RCTs were included, with overall good quality, but large heterogeneity. SPMC had slightly better quality of bowel cleansing than PEG (pooled RR 1.06; 95% CI 1.02 to 1.11).

In most trials, SPMC was significantly better tolerated than PEG. There were no significant differences in effectiveness or tolerability between SPMC and NaP. Side effects were similar between agents, except for dizziness (pooled RR 1.71; 95% CI 1.32 to 2.21 in favour of PEG vs SPMC) and vomiting (pooled RR 0.35; 95% CI 0.13 to 0.95 in favour of single-dose SPMC vs splitdose). PEG-based electrolyte solutions (PEG-ELS) and the combination of SPMC are commonly used bowel preparation agents. The aim of another study (Leitao et al 2014) was to compare the two agents with regard to cleansing efficacy and tolerance among individuals scheduled for outpatient colonoscopy.

The 368 colonoscopy outpatients at three Norwegian hospitals were randomised to bowel lavage with either PEG-ELS or SPMC. Compliance and patient tolerance were evaluated using a patient questionnaire. Bowel cleansing was evaluated using the Ottawa Bowel Preparation Quality Scale (OBPS), a validated scoring system with scores between 0 (best) and 14.

Results: There was no difference in the cleansing quality between the PEG-ELS and SPMC groups (median OBPS 5.0 in both groups). The group that received SPMC reported better overall patient tolerance than the PEG-ELS group (72.6 % vs 59.0 % reporting no or slight discomfort, P < 0.01).

Compliance with the recommended total fluid intake (4L) was better in the SPMC group than in the PEG-ELS group (94% vs 81% respectively, P < 0.01).

Moreover, the polyp detection rate was superior (34% vs 23%, P = 0.02).

CONCLUSIONS

PEG-ELS and SPMC are equally effective in cleansing efficacy, but SPMC was better tolerated by patients and resulted in superior patient compliance

and polyp detection rate.

The second trial concluded that SPMC is equally effective to NaP and little superior to PEG in terms of bowel cleansing. SPMC preparations were

better tolerated than PEG preparations.

SPMC may be considered as standard bowel preparation for colonoscopy.

References available on request.

SMOOTH OPERATOR

Scopex CO ®

An effective combination of hyoscine butylbromide and metamizole sodium to relieve smooth muscle pain and spasm:1-3 • abdominal pain and spasm1 • biliary and renal colic associated with abdominal pain1 • spastic functional dysmenorrhoea1

73%

• spastic conditions of the female genital system1

price saving 4 vs. originator

Effective and affordable pain relief, when more than just an antispasmodic effect is required.1-4

References: 1. SCOPEX® CO TABLETS Approved Package Insert, December 1969. 2. Tytgat GN. Hyoscine Butylbromide A Review of its Use in the Treatment of Abdominal Cramping and Pain. Drugs 2007;67(9):1343-1357. 3. Dawood Al-Waili NS, Saloom KY. Intravenous Tenoxicam to Treat Acute Renal Colic: Comparison with Buscopan Compositum. JPMA 1998;48:370-372. 4. Generics Dictionary. [online] Available at: http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_name_eq%5D=HYOSCINE-N-BUTYLBROMIDE+10mg%2C+Metamizole+sodium+monoh ydrate+250mg&q%5Bmanufacturer_name_cont%5D=&q%5Bbrand_cont%5D= [Accessed 19 May 2021].

S4 Scopex® CO Tablets. Each tablet contains hyoscine butylbromide 10 mg and metamizole sodium 250 mg. Ref. No. B1255 (Act 101/1965).

For full prescribing information refer to the professional information approved by the medicines regulatory authority.

Adcock Ingram Limited. Reg. No.: 1949/034385/06. 1 New Road, Midrand, 1685. Private Bag X69, Bryanston, 2021.

Tel.: +27 11 635 0000. www.adcock.com 202007141045391

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GASTROENTEROLOGY Focus CLINICAL | GASTROENTEROLOGY

continued from page 30

particular case. Often a child’s marks will drop, they can’t pay attention, and are then thought to have ADHD.” “It should be a red flag in children don’t develop properly,” stated Prof Schreiber.

“There is shame around this disease.”

She explained that patients need to go to the toilet often, there is urgency (sometimes a matter of 30 seconds), diarrhoea, and patients sometimes soil themselves if they can’t access a toilet quick enough.

“Some patients are so exhausted they can’t move or perform any tasks. This is a daily reality for many. Patients give up

their jobs due to huge fatigue. People don’t understand, because the patient may appear normal,” emphasised Prof Schreiber.

He shared that 15 years ago, people with a stoma bag weren’t allowed in public pools, even though no stool escapes. Patients are often in the prime of their lives. Travel, studies and work are all impacted.

IBD is often mistaken for irritable bowel syndrome - the most common condition that gastroenterologists encounter.

“There is an unmet need in the disease.

Before anti-TNF biologics, we could only put in hospital with parenteral nutrition.

Even hospital bed availability is scarce, beds are given for other conditions. Even in the emergency rooms, it is not seen as a priority.

When it comes to funding, IBD is not given attention, the intestines are not seen as a priority,” said Prof Schreiber.

TREATMENT Biological drugs are a class of monoclonal antibody immune suppressant medications first used to treat IBD in 1995. They are the most effective of all the IBD medications and are life changing for many patients.

However, after 25 years, these drugs remain

SMOOTH OPERATOR Prolonged release mesalazine for patients with mild-to-moderate ulcerative colitis1,2

largely inaccessible to the majority of IBD patients in South Africa. They can cost R200-300K a year and some come with some side effects. “In private healthcare, patients with medical aid sometimes need to escalate treatment and their plan doesn’t cover the medications they need. Only the top echelon plans cover biologics. It becomes difficult to motivate and fight for these drugs, when the only next option is surgery,” said Sr Davidson.

However, she explained that if you look at the cost for medical schemes over 10 years if the patient doesn’t have access to the drugs, it’s a ‘no brainer’.

Biosimilar drugs are not yet registered for use in SA. “We need to build more patient advocacy. Patients and healthcare providers aren’t vocal enough. It is not a glamourous disease and we need to advocate this. The fight needs to be taken to SAHPRA. The length of time taken for meds to be approved is criminal. Patients and healthcare professionals need to fight for this. Drugs that are available all over the world are sitting in a pipeline here.

She emphasised that not all patients will be put on the same drugs. Treatment is tailored. “Newer biologics come in, but they won’t be for everyone. However, in some patients you can change an entire life of a young patient,” she said, emphasising the importance of a multidisciplinary approach, using a range of healthcare professionals.

*

Scopex CO ®

LASTING REMISSION1,3-5 MMX®† TECHNOLOGY1,2 ALWAYS ONCE DAILY1

An effective combination of hyoscine butylbromide and metamizole sodium to relieve smooth muscle pain and spasm:1-3 MEZAVANT IS INDICATED FOR:1

Sr Karin Davidson, a specialist IBD nurse and Prof Stefan Schreiber, international IBD expert

1 treatment and maintenance of remission in ulcerative colitis •The abdominal pain and spasm

biliary associated The • approved Mezavantand package renal insert shouldcolic be consulted before prescribing. with abdominal pain Frequent adverse drug reactions: Hypersensitivity, headache, flatulence, 1nausea, abdominal distension, abdominal pain, colitis, diarrhoea, dyspepsia, vomiting, abnormal liver function test, spastic functional dysmenorrhoea • back pain, asthenia, face oedema, fatigue, pyrexia. arthralgia, Less frequent adverse drug reactions: Dizziness, somnolence, tachycardia, hypertension, hypotension,1 pharyngolaryngeal pain, pancreatitis, rectal polyp, increased alanine aminotransferase, spastic conditions of the female genital system acne,•alopecia, prurigo, pruritus, rash, urticaria, renal failure.

Contraindications: History of hypersensitivity to salicylates (including mesalazine) or to any of the excipients, severe renal impairment and/or severe hepatic impairment. price saving Warnings and special precautions for use: Renal impairment, chronic lung function impairment/asthma, hepatic impairment, allergy to sulphasalazine, blood dyscrasias, predisposure to r 4 vs. originato andsyndrome, affordable pain relief, myo-Effective or pericarditis, acute intolerance porphyria, elderly, obstruction in the upper gastrointestinal tract and nephrotoxicity.

1

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more than just It is when recommended that all patients have an evaluation of renalan functionantispasmodic prior to initiation of therapy and at least twice a year, while on treatment.1 ® 1-4Each tablet contains mesalazine 1 200 mg. Reg. No. 45/11/0463. For full prescribing information refer to the package insert approved by the Mezavant (entericis coated, prolonged release tablet.) effect required. medicines regulatory authority. 2019100310165518.

References: 1. Mezavant approved package insert, August 2013. 2. Brunner M, et al. Gastrointestinal transit and 5-ASA release from a new mesalazine extended-release formulation. Aliment Pharmacol Ther. 2003;17:395–402. ® References: 1. SCOPEX CO TABLETS Approvedin Package Insert, December 1969.

2. Tytgat GN. HyoscineGR,Butylbromide A Review of itsMMX UseMesalamine in the Treatment 3. Kamm MA, et al. Once-Daily, High-Concentration MMX Mesalamine Active Ulcerative Colitis.

Gastroenterology.

2007;132:66–75.

4. Lichtenstein et al. Effect of Onceor Twice-Daily (SPD476) for of theAbdominal Cramping and Pain. Drugs Induction of Remission of Mild to Moderately ActiveAl-Waili UlcerativeNS, Colitis.Saloom Clin Gastroenterol Hepatol. 2007;5:95–102.

5. Kamm MA, Acute et al. Randomised trial of Comparison once- or twice-daily mesalazine Compositum. for maintenance ofJPMA remission in 2007;67(9):1343-1357.

3. Dawood KY. Intravenous Tenoxicam to Treat Renal Colic: withMMX Buscopan 1998;48:370-372.

4. Generics Dictionary. ulcerative colitis. Gut. 2008;57:893–902.

[online] Available at: http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_name_eq%5D=HYOSCINE-N-BUTYLBROMIDE+10mg%2C+Metamizole+sodium+monoh

*Mezavant is the registered trademark used under licence from Nogra Pharma Limited.

[Accessed 19 May 2021]. † MMXydrate+250mg&q%5Bmanufacturer_name_cont%5D=&q%5Bbrand_cont%5D= and MMX Multi-Matrix System are registered trademarks of Cosmo Technologies Limited.

Scopex CO Tablets.

Each tablet contains hyoscine butylbromide 10 mg and metamizole sodium 250 mg. Ref. No. B1255 (Act 101/1965).

ForS4 general enquiries contact Helpdesk.Medinfo@adcock.com ForFor adverse events reporting contactrefer Adcock.Aereports@adcock.com or call 011 635 0000 full prescribing information to the professional information approved by the medicines regulatory authority. ®

Adcock Ingram Limited. Reg. No.: 1949/034385/06. 1 New Road, Midrand, 1685. Private Bag X69, Bryanston, 2021.

Tel.: +27 11 635 0000. www.adcock.com 202007141045391 ©2017 Shire. All rights reserved. SHIRE and the Shire logo are registered trademarks of Shire Pharmaceutical Holdings Ireland or its affiliates.

EXA/ZA//0002 Date of Preparation May 2017

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THE GP’s ROLE Dr Epstein’s take-home message for GPs is to have an awareness that IBD is common and increasing, and is often under recognised. Certain test such as stool calprotectin is a great screening tool to see if someone has inflammation in their gut. It is a chemical tests done on stool, and if the level is high, it suggests there is inflammation in the gut, possibly caused

by IBD. That should raise an alarm that this young patient may have IBD. The IBD Africa website (ibdafrica.org) has a list of every gastroenterologist in the country, where patients can get appropriate care. “If you think a patient has IBD, refer that patient to a gastroenterologist,” he concluded.

CLINICAL | GASTROENTEROLOGY

Bowel prep

GASTROENTEROLOGY Focus

education app is effective A study just released by Walter B et al, showed that patients who used a smartphone application in addition to standard instructions had improved bowel preparation quality.

O

PTIMAL BOWEL PREPARATION is an essential feature of high-quality colonoscopy, but inadequate preparation is still a common clinical problem. The success of colonoscopy is linked closely to the adequacy of bowel prep.

Inadequate colon preparation is associated with reduced adenoma detection rates. Despite its importance, around 20 -25 % of bowel preparations in clinical practice remain inadequate. Modifiable risk factors that can be crucial to ensure an adequate prep include patient guidance and education. In a study conducted last year, Desai Madhav et al evaluated the evidence with regard to the impact of education via smartphone app on bowel preparation.

They performed pooled analysis of 1665 patients undergoing colonoscopy and found that using a smartphone-based app was effective in improving bowel cleansing. Their meta-analysis showed that a 10 % higher adequate bowel preparation was achieved in the smartphone app group compared with the standard patient instruction group alone. Patients using the smartphone app had higher bowel preparation scale scores compared to controls.

The studies included were heterogeneous in terms of study design, study population, methodology and most importantly, type of bowel prep as well as type of smartphone application used.

Interventions in the form of simple cards with photographs and text explaining the rationale for bowel preparation have often failed to improve the quality of bowel preparation for colonoscopy. However, other studies using visual aids or an educational video, as interventions, have shown a positive effect on quality of bowel preparation. The use of telephone and

38 MAY 2020 | MEDICAL CHRONICLE

mobile messages to enhance education on diet restrictions and bowel preparation and serve as reminders have also led to improvements in bowel preparation.

These results indicate that education by more interactive audiovisual methods may be needed to improve bowel cleansing.

A smartphone app is another way of accomplishing that by displaying text instructions, visual aids, and alerts to the patient with regard to the diet restrictions required, a reminder to start the prep as well as the timing of the split dosing.

With the increasing use of smartphones, apps for bowel prep have the advantage of delivering information in a more user friendly format than some of the other educational methods. Another advantage is the use of automatic alerts, reminders, and notifications as well as the ability to go back to review the instructions about the bowel prep. The time interval between a scheduled colonoscopy and the initial delivery of instructions about bowel prep is often quite long. As a result, patients can easily forget the essential and pertinent instructions and can also misplace any written instructions that were provided at the initial contact.

Here is where the smartphone apps or mobile social media apps have an edge, as these will always be available to the patient along with the ability to serve reminders.

There can however, also be impediments to the implementation of smartphone apps for bowel cleansing. It requires a smartphone with a service network that may not be available or accessible to all. Smartphones may have a lower penetration in developing countries and possibly in uninsured populations in developed countries. Patients may not be familiar with social media or smartphone apps, and they may need

STUDY In a multicentre, randomised, controlled trial, investigators in Germany assessed the effect of a commercially available smartphone application on bowel preparation quality in 500 patients undergoing screening or surveillance colonoscopy. All participants received standard oral and written instructions. Those randomised to the intervention group downloaded an application that provided additional education, visual aids, and push notifications in the three days prior to colonoscopy.

Compared with the control group, patients in the app group had the following improved outcomes: • A significantly higher mean Boston bowel preparation scale (BBPS) score (7.6 vs 6.7) and higher segmental scores in the left, transverse, and right colon • A significantly higher rate of excellent preparation, defined as BBPS score ≥8 (61% vs 35%) • A significantly lower rate of inadequate preparation, defined as BBPS score <6 (8% vs 17%).

• A significantly higher adenoma detection rate (36% vs 27%) • Improved compliance with purgative and dietary instructions • A higher level of satisfaction with the bowel preparation process.

The results of this study apply only to motivated patients who own smartphones, but several other interventions are currently available to augment standard bowel preparation instructions, including text messaging and social media. The digitalisation and automation of the bowel prep instruction process appears inevitable and is associated with measurably better outcomes. assistance to navigate these making it more tedious and cumbersome than other simpler ways of education. There is a lack of a standardised smartphone app that is widely available for use and in use. Several different apps were used in the studies included in this meta-analysis and probably contributed to the clinical heterogeneity.

CONCLUSION In conclusion, use of a smartphone-based app improves bowel preparation and possibly patient satisfaction. This is an attractive option to improve the quality

of bowel prep but further research is needed to develop a standardised platform for uniformity.

REFERENCES Walter B et al. Smartphone application to reinforce education increases high-quality preparation for colorectal cancer screening colonoscopies in a randomized trial. Clin Gastroenterol Hepatol 2020 Mar 30; [e-pub]. (https://doi.org/10.1016/j. cgh.2020.03.051) Desai, Madhav et al. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endoscopy international open vol. 7,2 (2019): E216-E224. doi:10.1055/a-0796-6423.

MEDICAL CHRONICLE 19

CLINICAL | GASTROENTEROLOGY

Medical vs surgical

Treatment for refractory heartburn Antireflux surgery may be beneficial for refractory gastro-oesophageal reflux disease (GORD), but only for a highly selected group of patients, according to a New England Journal of Medicine study.

H

EARTBURN THAT PERSISTS despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with refluxreducing medication or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators.

Roughly 370 Veterans Affairs patients with heartburn refractory to proton-pump inhibitors were enrolled, but 288 were excluded for various reasons (eg, testing revealed non-GORD causes of heartburn).

Ultimately, 78 patients were randomised to receive either laparoscopic fundoplication, medical treatment (omeprazole, baclofen, desipramine), or control medication (omeprazole plus placebo).

At 12 months, the proportion of patients who had treatment success (at least a 50% improvement in the GORD Health-Related Quality of Life score) was significantly higher in the surgery group (67% vs. 28% for active medication and 12% for control medication).

An editorialist cautions: "The findings should not translate into more patients with refractory heartburn being offered surgery without each case being judiciously evaluated on its merits, and only after extended trials of medical therapy."

METHODS Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20mg of omeprazole twice daily for two weeks, and those with persistent heartburn underwent endoscopy, oesophageal biopsy, oesophageal manometry, and multichannel intraluminal impedance–pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the GORD– Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at one year.

RESULTS A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled.

Prerandomisation procedures excluded 288 patients: 42 had relief of their heartburn during the two-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had nonGORD oesophageal disorders, and 99 had

functional heartburn (not due to GORD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomisation. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to

that with active medical treatment (seven of 25 patients, 28%; P=0.007) or control medical treatment (three of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and

the control medical group was 16% points (95% confidence interval, −5 to 38; P=0.17).

References available on request.

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*GORD = gastro-oesophageal reflux disease

References: 1. Scholten T, Gatz G, Hole U. Once-daily pantoprazole 40 mg and esomeprazole 40 mg have equivalent overall efficacy in relieving GERD-related symptoms. Aliment Pharmacol Ther 2003;18:587-594. 2. Devault KR. PPI – proton apump inhibitor; OTC –inhibitor over-the-counter Pantoprazole: proton pump with oral and intravenous formulations. Expert Rev Gastroenterol Hepatol *If symptom control has not been achievedPrices. after 2 (Online) weeks of21 treatment 20[Cited mg (one capsule) daily, further investigation 2007;1(2):197-205.

3. Database of Medicine August with 2019.

9 September 2019].

Available from is recommended.

URL:References: http://www.mpr.gov.za/PublishedDocuments. aspx#DocCatId+21.

1. Bate CM, Booth SN, Crowe JP, et al. Omeprazole 10 mg or 20 mg once daily in the prevention of recurrence of reflux oesophagitis. Gut 1995;36:492-498. 2. ADCO OMEPRAZOLE 20 capsules

® Approved Package July 2004. 3. RAPACID CapsulesReg. Approved Insert, 09 December 4. National Institute for Health and Care Excellence (NICE) Clinical Guideline CG184 GastroS4 PANTOCID 20Insert, mg 23 (Enteric-coated tablets).

No.:Package 41/11.4.3/0787.

Each2008. tablet contains pantoprazole ® oesophageal reflux disease and dyspepsia in adults: investigation and S4 management.

September 2014.(Enteric-coated Available at www.nice.org.uk/guidance/cg184.

Last Accessed May 2021. 5. Armstrong D, Nakhla N. sodium sesquihydrate equivalent to 20 mg pantoprazole.

PANTOCID 40 mg tablets). Reg. proton-pump self-treating frequent heartburn: the role of the Canadian equivalent pharmacist. Pharmacy Practice 2016;14(4):868. 6. TPM MAT/03/2021. A2/B2 (Proton Pump Inhibitors oral No.: Non-prescription A 40/11.4.3/0482.

Eachinhibitors tablet for contains pantoprazole sodium sesquihydrate to 40 mg pantoprazole. units) Market.

7.

Generics Dictionary. [online] Available at: http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_name_eq%5D=OMEPRAZOLE&q%5Bmanufacturer_ Contains sugar: lactose (anhydrous). Pharmacological classification: A 11.4.3 Medicines acting on gastro-intestinal [Accessed 27 May powder 2021]. lyophilised for injection). Reg. No.: A 40/11.4.3/0072. Each vial tract.name_cont%5D=&q%5Bbrand_cont%5D= S4 PANTOCID® 40 mg (Injection contains pantoprazole sodium equivalent 40omeprazole. mg pantoprazole.

Sugar free. Pharmacological cation: 11.4.3 S2 Adco OmeprazoleClassifi capsule. Each capsule contains 10tomg Reg. No.: A39/11.4.3/0466.

20 capsule.

Each A capsule contains 20 mg omeprazole. Reg. No.: 37/11.4.3/0228.

S2 RapAcid Medicines acting on the gastro-intestinal tract. Applicant: Ranbaxy Pharmaceuticals (Pty) Ltd., a Sun Pharma company.

For full Road, prescribing information, please refer to the professional approved SAHPRA African Health Products Regulatory Authority).

14 Lautre Stormill Ext.1, Roodepoort, 1724. Tel: information +27 11 495 0100.byFax: +27(South 11 495 0150. www.sunpharma.com For full prescribing information, refer to the Professional Regulatory Adcock Ingram Limited.

Reg. No.: 1949/034385/06.

1 New Road, Information Midrand, 1685.approved Private Bag by X69,the Bryanston, 2021. Authority.

Tel.: +27 11 635 0000. www.adcock.com 2019110110171460

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2021/05/28 11:54

MEDICAL CHRONICLE | MAY 2020 33 MEDICAL CHRONICLE 21

GASTROENTEROLOGY Focus CLINICAL | GASTROENTEROLOGY

Chronic constipation treatment should be natural

Is your patient constipated? The answer to this question depends entirely on your definition of the condition.

B

REASTFED BABIES, children and some adults will defecate while eating and/or minutes thereafter. This response is viewed as being normal but unfortunately destroyed in most by our civilising potty training. Babies and toddlers will however

continue to defecate after each meal.

WHAT IS NORMAL? Based on the above physiology it appears that normal might be a stool before breakfast and a second before bed in the

evening. Big meals produce big stools and fasting constipation. If we follow general consensus, constipation is defined as less than three stools a week. Many patients who are ignorant of this classification view themselves as constipated in spite

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Prednisolone Caproate & Cinchocaine Hydrochloride ANUSOL® OINTMENT: Reg. No. E/11.8/0513. Each 1 g of ointment contains: Bismuth Subgallate 22,5 mg.

References: 1. Abramowitz, The Diagnosis and Zinc Management of Haemorrhoidal from a Global Perspective. Aliment Pharmacol Ther. May 2010;31(1):1-58. 2. Scheriproct Suppositories approved package insert, 3 Aug 2000. 3. Scheriproct Ointment approved package insert, 3 Aug 2000.

Bismuth OxideL. 8,75 mg, Oxide 107,5Disease mg. ® ANUSOL SUPPOSITORIES: No. E/11.8/0515.

Each suppository contains: Bismuth Subgallate 1 suppository contains Reg. prednisolone caproate (1,4-pregnadiene-3,20-dione-11β-17α,21-triol-21-caproate) 1,3 mg and cinchocaine hydrochloride as the hydrochloride 59,0 of (2-butoxy-N-(2-diethylaminoethyl)cinchonamide) 1 mg. Reg. No.: E/11.8/0668. S4 SCHERIPROCT OINTMENT. 1 g ointment contains S4 SCHERIPROCT SUPPOSITORIES. prednisolone caproate (1,4-pregnadiene-3,20-dione-11β-17α,21-triol-21-caproate) 1,9 mg and cinchocaine hydrochloride as the hydrochloride of (2-butoxy-N-(2-diethylaminoethyl)cinchonamide) 5 mg. Reg. No.: E/11.8/0667. mg, Bismuth Oxide 24,0 mg, Zinc Oxide 296,0 mg.

Under licence from Karo Pharma Stockholm, Sweden. For full prescribing information refer to the professional information approved by the medicines regulatory authority.

For full prescribing information, refer to the package insert approved by the Medicines Control Council.

Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Telephone + 27 11 635 0000. www.adcock.com. 16908J. 202102101086376.

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of daily defaecation. The most commonly used definition is the Rome lll criteria. It is useful to review the criteria for the irritable bowel syndrome at the same time. These various criteria mean that a patient who has constant flatus in the late afternoon and passes a formed stool at 5pm five days of the week is not constipated. These formalised definitions may be useful for comparing patients in studies but are quite useless in daily clinical practice. An alternative patient centric approach is needed. At the simplest level the definition of normal might be the easy passage of stool not associated with unpleasant symptoms.

WHAT IS CONSTIPATION? Constipation is the passing of stood with difficulty and associated with the unpleasant symptoms of the passage of wind while doing ones daily functions, spontaneous abdominal cramps and cramps related to defaecation. Symptoms of the irritable bowel are bloating (which incidentally is not related to intestinal gas), feelings of incomplete evacuation and inappropriate calls to defaecation.

Mucous on the stool appears in both these overlapping conditions.

The abnormal physiology of constipation is slow colonic transit and subsequently dehydrated stools. Before examining these abnormalities, the secondary causes of constipation need to be excluded.

WHY DO SOME PATIENTS NOT RESPOND? The main reason for failure is the underestimation of the irritable bowel component of the patient’s symptoms.

A characteristic of irritable bowel is the disproportionate discomfort experienced as a result of rectosigmoid distension.

Sometimes these patients land up in a vicious circle, increasing stimulatory laxatives, which empty the colon but conversely increases sensitivity to small amount of residual stool. The presence of this is uncomfortable and results in strong feelings of incomplete evacuation and a desperate need to take further laxatives to clear the colon. These patients have serious bowel function misconceptions and need intensive supportive therapy.

THE WAY FORWARD We need to move the population towards caring for their colonic function with adequate fibre and particles in the diet and away from the need for laxatives, excessive fluids, bowel washouts and the new panacea – probiotics.

References available on request.

22 MEDICAL CHRONICLE 24 NOVEMBER 2019 | MEDICAL CHRONICLE

Prolonged release mesalazine for patients with mild-to-moderate ulcerative colitis1,2

GASTROENTEROLOGY Focus

2

Mezavant® is a valuable option in the management of patients with mild to moderate ulcerative colitis1

MMX® TECHNOLOGY FOR PROLONGED DRUG RELEASE2-5

DELIVERS MESALAZINE (5-ASA) THROUGHOUT THE COLON2-5

ALWAYS ONCE DAILY2

HIGH-DOSE FORMULATION REDUCES THE DAILY TABLET BURDEN1

IMPROVED ADHERENCE TO TREATMENT6

MEZAVANT IS INDICATED FOR:2 The treatment and maintenance of remission in ulcerative colitis The approved Mezavant professional information should be consulted before prescribing.

5-ASA: 5-acetyl salicylic acid References: 1. Yang LPH, McCormack PL. MMX® Mesalazine: A review of its use in the management of mild to moderate ulcerative colitis. Drugs 2011;71(2):221-235. 2. Mezavant approved package insert, August 2013. 3. Brunner M, Assandri R, Kletter K, Tschurlovits M, Corrado Me, Villa R, et al.

Gastrointestinal transit and 5-ASA release from a new mesalazine extended-release formulation. Aliment Pharmacol Ther. 2003;17:395–402. 4. Tenjarla S, Romasanta V, Zeijdner E, Villa R, Moro L. Release of 5-aminosalicylate from an MMX mesalamine tablet during transit through a simulated gastrointestinal tract system. Advances in Therapy 2007;24(4):826-840. 5. Tenjarla S, Abinusawa A. In-vitro characterization of 5-aminosalicylic acid release from MMX mesalamine tablets and determination of tablet coating thickness. Adv Ther 2011;28(1):62-72. 6. Simoni SE, Felipsen SF, Conegero Sanches AC, Vasconcelos HL. Multi-Matrix 5-Aminosalicylic Acid Efficacy in Induction of Remission in Mild-to-Moderate Ulcerative Colitis: A Systematic Review. International Journal of Health Sciences, September 2019;7(3): 42-51.

Mezavant® (enteric coated, prolonged release tablet.) Each tablet contains mesalazine 1 200 mg. Reg. No. 45/11/0463. For full prescribing information refer to the professional information approved by the medicines regulatory authority.

To report an Adverse Event, e-mail Adcock.AEReports@adcock.com or call 011 635 0134 To request a copy of the current approved package insert or references, e-mail:Helpdesk.MedicalAffairs@adcock.com ©2019 Shire. All rights reserved. SHIRE and the Shire logo are registered trademarks of Shire Pharmaceutical Holdings Ireland or its affiliates Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa.

Telephone + 27 11 635 0000. www.adcock.com. 16538J. 202102241089543. C-APROM/ZA/MEZ/0003.

MEDICAL CHRONICLE 23

GASTROENTEROLOGY Focus CLINICAL

GASTROENTEROLOGY

ANTIBIOTICS: DO PROBIOTICS PROTECT AGAINST IN DIARRHOEA? Probiotics are microorganisms that are believed to improve health by maintaining a normal balance of microorganisms in the human intestines.

Taking probiotics can reduce the risk of developing the diarrhoea that is a common side effect of taking antibiotics. They are contained in some food products and also are sold LP299V A4 Advert 0421 V2 P.pdf as nutritional supplements.

Pooling evidence from a large number of published research studies examining the effects of probiotics, researchers found consistent evidence that probiotics can benefit people who 1 2021/04/13 9:56 AM are taking antibiotics.

“We found a clear beneficial effect of probiotics in preventing or treating antibiotic-associated diarrhoea,” said study co-author Sydne Newberry, a nutritional scientist and a researcher at Rand, a non-profit research

organisation. “However, more work is needed to determine which types of probiotics work best, which patients are most likely to benefit from probiotics and whether there are any risks in using them.” As many as 30% of patients who take antibiotics suffer from diarrhoea, a side effect that is a key reason why some patients do not follow through with a full course of antibiotic treatment. Interest in the possibility that probiotics might help or prevent this type of diarrhoea has grown in recent years, resulting in a proliferation of individual studies.

Use of probiotics was associated with a 42% lower risk of developing diarrhoea when taking antibiotics Researchers from the Rand-based Southern California Evidence-Based Practice Center conducted an extensive review of the medical literature to find studies that examined whether probiotic use can prevent and treat antibiotic-associated diarrhoea.

Researchers pooled results from the studies together to gain a clearer understanding of whether probiotics can prevent or treat antibioticassociated diarrhoea.

Use of probiotics was associated with a 42% lower risk of developing diarrhoea when taking antibiotics as compared to not using probiotics.

The Rand analysis estimates that 13 people would need to use probiotics in order to prevent one case of antibiotic-associated diarrhoea.

However, researchers say the evidence was insufficient to show which type of microorganism was better than another because the included strains were poorly documented and often given as blends of several types.

Further, there was no indication that the response varied systematically by a person’s age, the duration of antibiotic use or other clinical indications.

The Rand team says that future efforts to study the effects of probiotics should try to determine whether some strains or combinations of probiotics work better than others, work best with specific antibiotics, and whether use of probiotics for antibioticassociated diarrhoea is associated with any health risks.

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2017/08/24 8:20 PM

MEDICAL CHRONICLE 25

CLINICAL GASTROENTEROLOGY Focus PAEDIATRIC GASTROENTEROLOGY

STOPPING REFLUX

Infant reflux occurs when food refluxes from a baby's stomach, causing the baby to regurgitate.

Sometimes called gastrooesophageal reflux disease (GORD), the condition is rarely serious and becomes less common as a baby gets older. It's unusual for infant reflux to continue after 18 months. Reflux occurs in healthy infants multiple times a day. As long as the infant is healthy, content and growing well, the reflux Adco-Mayogel A4 Rarely, Advert 0421 V4 is not a cause for concern.

infant reflux can be a sign of a medical problem, such as an allergy, a blockage in the digestive system or GORD.

HOW INFANT REFLUX OCCURS

In infants, the ring of muscle between the esophagus and the stomach - the lower esophageal sphincter (LES) - is P.pdf 11:08 AM not yet1fully2021/04/08 mature. That allows

stomach contents to flow backward.

Eventually, the LES will open only when the baby swallows and will remain tightly closed at other times, keeping stomach contents where they belong.

The factors that contribute to infant reflux are common in babies and often can't be avoided. These factors include: • Babies lying flat most of the time • An almost completely liquid diet

• Babies being born prematurely.

Occasionally, infant reflux can be caused by more-serious conditions, such as: • GORD: The reflux has enough acid to irritate and damage the lining of the esophagus.

• Pyloric stenosis: A valve between the stomach and the small intestine is narrowed, preventing stomach contents from emptying into the small intestine.

• Food intolerance: A protein in cow's milk is the most common trigger.

• Eosinophilic oesophagitis: A certain type of white blood cell (eosinophil) builds up and injures the lining of the oesophagus.

COMPLICATIONS

Infant reflux usually clears up by itself without causing problems for your baby.

If your baby has a more-serious condition such as GORD, he or she might show signs of poor growth. Some research indicates that babies who have frequent episodes of spitting up may be more likely to develop GORD during later childhood.

DIAGNOSIS

If testing includes: • Ultrasound: This imaging test can detect pyloric stenosis.

• Lab tests: Blood and urine tests can help identify or rule out possible causes of recurring vomiting and poor weight gain.

• Oesophageal pH monitoring: To measure the acidity in the baby’s oesophagus • X-rays: Can detect abnormalities in the digestive tract, such as an obstruction. Your baby may be given a contrast liquid (barium) from a bottle before the test.

• Upper endoscopy: Tissue samples may be taken for analysis. For infants and children, endoscopy is usually done under general anesthesia.

SELF-MANAGEMENT

To minimise reflux, the baby should be fed in an upright position. It is recommended to hold the baby in a sitting position for 30 minutes after feeding. Gravity can help stomach contents stay put. Be careful not to move the baby too much while the food is settling. Try smaller, morefrequent feedings, taking time to burp the baby. Frequent burps during and after feeding can keep air from building up in the baby's stomach. Most babies should be placed on their backs to sleep, even if they have reflux.

References available on request.

19107 Gaviscon Infant JournalAd R.indd 1

26 FEB MEDICAL 34 2017 |CHRONICLE MEDICAL CHRONICLE

7/30/15 3:33 PM

GASTROENTEROLOGY CLINICAL Focus GASTROENTEROLOGY

STAYING NEUTRAL

The term ‘acid’ reflux tends to imply that the stomach juice that refluxes upward into the oesophagus causing symptoms is acid alone. However, the acid is the component of the stomach juice that causes irritation of the oesophagus and therefore, the symptoms.

Acid reflux is just another term for gastroesophageal reflux. The stomach juice that refluxes contains many chemicals, of which acid is only one. Drugs that are used to treat gastrooesophageal reflux disease (GORD) decrease or remove acid from the juices that are refluxing, but the reflux continues.

• Continuous hiccups • Nausea • Weight loss for no known reason • Wheezing, dry cough, hoarseness, or chronic sore throat.

• Bloody or black stools or bloody vomiting • Burping • Dysphagia - a narrowing of the oesophagus, which creates the sensation of food being stuck in the throat

Regurgitation: A sour or bitter-tasting acid backing up into your throat or mouth Other symptoms of acid reflux disease include: • Bloating

References available on request.

WHAT IS ACID REFLUX?

Acid reflux and GORD are one and the same. These terms can be used interchangeably. However, for proper understanding, further explanation is needed.

The juices that are contained within the stomach include a wide array of chemicals. These include bile, enzymes and others. The stomach also produces acid that is mixed with these other chemicals. Therefore acid is not the only thing that is refluxing, but the whole array of the chemicals in the stomach juice of which acid is only one.

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TOPZOLE®: SOUTH AFRICA’S NO.1 PPI PANTOPRAZOLE*1

ABOUT THE ACID

Heartburn is the most common symptom of acid reflux. The thought pattern that follows is if the acid is removed from the stomach juice, the irritant is gone. Even though the reflux of stomach juice is still occurring, symptoms do not happen.

This is exactly what happens when any of the medications for acid reflux (or GORD) are taken. The drugs either neutralise the acid in the stomach juice or decrease its production by the stomach. Reflux continues, but in the majority of situations symptoms are improved.

Notably, the actual cause of acid reflux is not addressed by the medications. The dysfunctional valve at the end of the oesophagus is not changed at all.

WHAT ARE THE SYMPTOMS? Common symptoms of acid reflux are: Heartburn: A burning pain or discomfort that may move from your stomach to your abdomen or chest, or even up into your throat.

• Effective GORD symptom relief2 • Daily pantoprazole maintenance therapy for severe acid-peptic disease is effective and well tolerated for up to 15 years3 • Low potential for drug interactions4 • TOPZOLE® 20 mg is suitable for on-demand use, once daily, when required5 DOSAGE Duodenal ulcer

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OD for 4 weeks. May be repeated for another 4 weeks if complete healing has not been achieved within the first 4 weeks

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20 mg OD. May be increased to 40 mg OD should relapse occur, to be reduced to 20 mg OD once healing of relapse has been achieved

*in relation to sales value; GORD = Gastro-oesophageal reflux disease; OD = Once daily; PPI = Proton pump inhibitor References: 1. IMS Data, MAT Value 01/2021. 2. Scholten T, Gatz G, Hole U. Once-daily pantoprazole 40 mg and esomeprazole 40 mg have equivalent overall efficacy in relieving GERD-related symptoms.

Aliment Pharmacol Ther. 2003;18:587-594. 3. Brunner G, Athmann C, Scheider A. Long-term,open-label trial: safety and efficacy of continuous maintenance treatment with pantoprazole for up to 15 years in severe acid-peptic disease. Aliment Pharmacol Ther. 2012;doi:10.1111/j.1365-2036. 2012.05106.x:1-11. 4. Blume H, Donath F, Warnke A, Schug BS. Pharmacokinetic Drug Interaction Profiles of Proton Pump Inhibitors. Drug Safety. 2006;29(9):769-784. 5. Topzole Approved Package Insert. Takeda (Pty) Ltd. 2012 September 14.

S4 TOPZOLE® 20. Reg. No. 38/11.4.3/0061. Each enteric-coated tablet contains 20 mg pantoprazole. S4 TOPZOLE® 40. Reg. No. 38/11.4.3/0060. Each enteric-coated tablet contains 40 mg pantoprazole. For full prescribing information, refer to the Professional Information approved by the Medicines Regulatory Authority.

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11:41 27 AM MEDICAL2021/05/31 CHRONICLE MEDICAL CHRONICLE | AUGUST 2017 23

GASTROENTEROLOGY Focus CLINICAL | GASTROENTEROLOGY

Probiotic reduces crying in colicky infants

Evidence is mounting that probiotics can give babies relief from colic, a functional gastrointestinal disorder believed to be tied to disturbances in the gut microbiota.

A

LTHOUGH THE PATHOGENESIS of colic is unclear, a new study reports that the probiotic Bifidobacterium animalis subspecies lactis BB-12 effectively LP299V A4 Advert 0421 V2 P.pdf

eases infant colic. In a randomised, doubleblind, placebo-controlled trial, Rita Nocerino, CPN, of the Department of Translational Medical Science at the University of Naples 1 2021/04/13 9:56 AM

Federico II, in Italy, and colleagues found that treatment with BB-12 for 28 days was associated with a greater rate of reduced daily average crying time (≥50%) compared

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2. Fijan, S. Microorganisms with Claimed Probiotic Properties: An Overview of Recent Literature. Int. J. Environ. Res. Public Health 2014;11:4745-4767.

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4. Reference available on request.

5. Price Document, Data on File.

Probiflora Probiotic Infant Drops 3 strain-Regular drops. Each dose per 4 drops (0,167 ml) contains Bifidobacterium lactis 400 million CFU; Lactobacillus rhamnosus 300 Million CFU; Lactobacillus salivarius 300 million CFU. Health supplement. This unregistered medicine has not been evaluated by the South African Health Products Regulatory Authority for quality, safety or intended use. Adcock Ingram Limited (Pty) Ltd. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Tel. +27 11 635 0000 www.adcock.com 2019112510176679 To report an Adverse Event, e-mail Adcock.AEReports@adcock.com or call 011 6350134 To request a copy of the current approved package insert or references, e-mail: Helpdesk.MedicalAffairs@adcock.com

with placebo. The effect on crying time emerged as early as the first week of BB12 supplementation. The probiotic also appeared to have beneficial effects on sleep duration as well as stool frequency and consistency. The trial results were published in Alimentary Pharmacology and Therapeutics.

The researchers randomly assigned 80 healthy but colicky infants no older than seven weeks who were exclusively breastfed to receive placebo or a daily dose of BB-12 1 x 10 colony-forming units. The mean age of the babies was a little more than one month, and more than 50% were boys. The mean daily duration of crying bouts was consistently shorter in the BB12 group at each week and decreased from week to week. Mean change from baseline in the intention-to-treat population was significantly greater in the BB-12 group than the placebo group: –129.9 ± 43.7 and –84.3 ± 51.4, respectively (P = .0001).

In the per-protocol analysis, 80% of BB-12 recipients showed a ≥50% reduction in crying duration after 28 days, compared with 31.5% of those in the placebo group (P < .0001).

The mean number of daily crying episodes was lower in the BB-12 group at each study week. The mean change from baseline to the last week was –4.7 ± 3.4 in the intervention group vs –2.3 ± 2.2 in the placebo group (P = .001). Infants' sleeping time in both groups increased from baseline, with a mean change at the last week of 36.5 ± 98.8 minutes per day in the BB-12 group (range, –225.7 to 345.0 minutes) and 47.9 ± 108.6 minutes per day (range, –265.0 to 225.0 minutes) in the placebo group.

BB-12 recipients showed an increase in anti-inflammatory biomarkers in stool, including an abundance of Bifidobacterium as well as an increase in levels of butyrate, HBD-2, LL-37 and sIg, which are associated with a decrease in levels of the inflammatory marker calprotectin. That finding suggests that this probiotic strain has an immunomodulatory action in the infant gut.

Its beneficial effect could stem from both immune and nonimmune mechanisms that modulate the structure and function of the microbiota, the authors explain.

The researchers note that their results align those of an open-label trial in which BB-12, when added to a lowlactose, partially hydrolysed whey formula, decreased the duration of crying time in infants with colic. Other probiotics as well have reportedly had a beneficial effect on colic.

Source: Medscape, Mediclinic Infohub 28 MEDICAL CHRONICLE 40 MAY 2020 | MEDICAL CHRONICLE

CLINICAL

GASTROENTEROLOGY

HOW TO IMPROVE

GASTROENTEROLOGY Focus

BOWEL PREP

Colonoscopy is crucial in investigating large bowel pathologies including surveillance for CRC (colorectal cancer). Poor bowel preparation is one of the most important factors affecting diagnosis.

Different formulations of bowel prep are currently in use depending upon patient tolerance, indication and co-morbidities.

The authors of a UK-based study (2017) noticed that quality of bowel preparation noticeably improved from 80% to almost 93% if patients were given appropriate advice in a written format, prior to procedure. For optimal assessment of large bowel with colonoscopy, it is imperative to have a good bowel preparation with minimal faecal contamination. Poor bowel preparation is the leading cause of failed colonoscopy examinations.

Numerous bowel cleansing agents are used. However, there is a noticeable limitation to their effectiveness due to variations in their tolerability and side effect profile. An inadequately prepared bowel can lead to missed diagnosis or need for repeat procedures and investigations, with a significant financial impact. A more standardised approach to choice of these agents can be helpful in achieving optimal bowel cleansing and assessment. Before endoscopic procedures and radiological imaging of the bowel, oral bowel cleansing preparations have long been in use to minimise bowel contamination for optimal assessment.

An ideal bowel cleansing agent should not only be effective in cleansing the bowel, but also well tolerated and convenient to use, with minimal side effect profile. Polyethylene glycols (PEGs) are non-absorbable solutions that pass through the bowel without absorption. They need to be taken in large amount of water and absorption of this can lead to fluid overload in predisposed individuals (eg those Asic 1-4 Advert 0521 with V5 P.pdf

Poor bowel preparation is the leading cause of failed colonoscopies

Chronic Kidney Disease or Congestive Cardiac Failure). Oral phosphate based preparations are mainly effective by drawing large amount of water into the gut and don't need to be taken with larger volumes of fluid. They can, however be associated with electrolyte imbalance and rapid fluid shifts, but are also cost effective. A good bowel prep gives adequate cleansing to the colon for optimal assessment. Different scales are used for scoring bowel preparation among different trusts with small variations and are based on the quality of bowel cleansing encountered during withdrawal of the scope. One of the most commonly used scales is the Boston Bowel Preparation Scale.

TIPS Patient tolerance8:12 and compliance 1 2021/05/04 AM

was an important factor in choosing bowel preparation and contributed towards poor results with patients not completing the regime.

Patient demographics (age, gender and cognitive level) are a very important factor in compliance with prescribed preparation and were not looked at.

Also this data includes some inpatient procedures. This might have affected the results based upon these variables; however this process affected all cycles randomly. Not everyone found it easy to comply with a specific diet plan a few days before the procedure.

CONCLUSION Poor bowel preparation is the leading cause of failed colonoscopies, resulting in delayed diagnosis and repeat investigations. A structured approach

towards bowel preparation choice and patient education leads to better quality of bowel cleansing and is likely to improve the diagnostic yield of the procedures. This also means less numbers of repeat investigations also leading to a better financial outcome.

Appropriate choice of less expensive yet equally effective bowel cleaning preparations along with their delivery to the patients can also be optimised in a much better cost effective manner.

References

Gardezi SA, Tibbatts C. Improving bowel preparation for colonoscopy in a cost effective manner BMJ Open Quality 2017;6:u204560. w5376. Doi: 10.1136/bmjquality.u204560. w5376.

Leitao K et al. Polyethylene glycol vs sodium picosulfate/magnesium citrate for colonoscopy preparation. Endosc Int Open 2014; 2(4):E230–E234.

28 FEBRUARY 2019 | MEDICAL CHRONICLE MEDICAL CHRONICLE 29

GASTROENTEROLOGY Focus CLINICAL GASTROENTEROLOGY

CAUSES OF STOMACH PAIN

For patients who present with stomach pain, there could be a multitude of causes for this ailment.

GASTRITIS

Gastritis is inflammation of the stomach lining and is usually termed acute or chronic gastritis.

The two major causes of gastritis are Helicobacter pylori or H. pylori, and NSAIDs. However, there are Adco-Loperamide A4 Advert 0421

many other causes like other infectious agents, autoimmune problems, diseases like Crohn's disease, sarcoidosis, and isolated granulomatosis gastritis. Treating the underlying cause of gastritis is the most effective way to reduce or resolve gastritis symptoms.

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PEPTIC ULCER These are open sores on the lining of the stomach or the upper part of the small intestine. The most common cause is bacteria, but again, long-term use of aspirin, ibuprofen, and other painkillers can play a role. And people who smoke or drink get these ulcers

more often. They're usually treated with antacids or antibiotics, depending on the cause.

STOMACH VIRUS Symptoms include watery diarrhoea, cramps, or nausea, and vomiting. It can be caught from someone else, or from contaminated food. It is usually a self-limiting condition, but a high fever, vomiting, dehydration, or blood in vomit in stools are warning signs for intervention and further investigation.

IRRITABLE BOWEL SYNDROME This common illness affects the colon.

It can cause cramping, bloating, and mucus in stool. Patients might alternate between diarrhea and constipation.

It’s not clear why it happens, but food, stress, hormones, and infection may all play a part. You can help these patients by controlling symptoms through changes in your diet or lifestyle, or medication, including: • Fibre supplements: Taking a supplement such as psyllium with fluids may help control constipation.

• Laxatives: If fibre doesn't help symptoms, your doctor may prescribe magnesium hydroxide oral or polyethylene glycol.

• Anti-diarrhoeal medications: Over-the-counter medications, such as loperamide can help control diarrhoea.

You could also prescribe a bile acid binder, such as cholestyramine, colestipol or colesevelam. Bile acid binders can cause bloating.

• Anticholinergic medications: Medications such as dicyclomine can help relieve painful bowel spasms.

They are sometimes prescribed for people who have bouts of diarrhoea.

These medications are generally safe but can cause constipation, dry mouth and blurred vision.

• Tricyclic antidepressants: This type of medication can help inhibit the activity of neurons that control the intestines to help reduce pain. For diarrhoea and abdominal pain without depression, you may suggest a lower than normal dose of imipramine, desipramine or nortriptyline. Side effects – which might be reduced when taking the medication at bedtime — can include drowsiness, blurred vision, dizziness and dry mouth.

• SSRI antidepressants: These may help if the patient is depressed and has pain and constipation.

• Pain medications: Pregabalin or gabapentin might ease severe pain or bloating.

References available on request.

14 MEDICAL MAY 2018CHRONICLE | MEDICAL CHRONICLE 30

CLINICALFocus GASTROENTEROLOGY

GASTROENTEROLOGY

GORD VS HEARTBURN: KNOW THE DIFFERENCE Gastro-oesophageal reflux disease (GORD) isn’t just heartburn or bad indigestion.

GORD (or GERD in the US) affects up to 40% of the population in Western countries.

Dr Eduan Deetlefs, Gastroenterologist at Mediclinic Milnerton, explains that GORD occurs when the stomach content refluxes past the lower oesophageal sphincter up into the oesophagus and even all the way into the throat or mouth.

Experiencing this kind of reflux occasionally is normal. However, over long periods of time, it could be a sign of GORD. “GORD develops when the lower oesophageal sphincter is more open than it should be or if there is a hiatus hernia,” says Dr Deetlefs. “Factors that can lead to a weakened, relaxed or open valve are: Increased pressure in the stomach due to obesity, overeating or pregnancy, certain foods that can cause relaxation of the valve, and certain medications.”

As with many other diseases, not everyone experiences the condition in the same way. Some patients have regurgitation and the burning sensation in the centre of the chest known as heartburn, while others develop atypical symptoms such as upper abdominal pain and a vague chest discomfort, says Dr Deetlefs. Sometimes, patients even experience the pain and symptoms of GORD as similar to that of a heart attack.

The condition is most commonly diagnosed by gastroscopy.

acid the stomach produces. If severe regurgitation still occurs after medication, surgery is an option. During a laparoscopic Nissen fundoplication, the lower oesophageal sphincter is

or two. Fortunately, surgery is rarely required.

Source: Mediclinic Infohub

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According to Dr Deetlefs, a diet high in spicy foods, fat and alcohol can most certainly contribute to the development of GORD - although patients can still develop it even if they’re perfectly healthy. It can ‘run in the family’, but researchers aren’t sure yet if that’s because families tend to eat the same foods or whether it’s in the genes.

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TREATMENT

There are three options, depending on the severity of the disease. Getting healthy is a good place to start, although Dr Deetlefs says making lifestyle changes is helpful for some patients, but not all. Healthy changes include regular exercise, losing weight if necessary, quitting smoking, and adjusting what and how much you eat. If these measures don’t ease symptoms, medication may be necessary.

Proton pump inhibitors (PPIs) regulate the amount of hydrochloric

strengthened, usually by wrapping part of the stomach around itself to create a new valve. The surgery requires a twoor three-day hospital stay, and patients can be back at work within a week

PPI – proton pump inhibitor; OTC – over-the-counter *If symptom control has not been achieved after 2 weeks of treatment with 20 mg (one capsule) daily, further investigation is recommended.

References: 1. Bate CM, Booth SN, Crowe JP, et al. Omeprazole 10 mg or 20 mg once daily in the prevention of recurrence of reflux oesophagitis. Gut 1995;36:492-498. 2. ADCO OMEPRAZOLE 20 capsules Approved Package Insert, 23 July 2004. 3. RAPACID Capsules Approved Package Insert, 09 December 2008. 4. National Institute for Health and Care Excellence (NICE) Clinical Guideline CG184 Gastrooesophageal reflux disease and dyspepsia in adults: investigation and management. September 2014. Available at www.nice.org.uk/guidance/cg184. Last Accessed May 2021. 5. Armstrong D, Nakhla N. Non-prescription proton-pump inhibitors for self-treating frequent heartburn: the role of the Canadian pharmacist. Pharmacy Practice 2016;14(4):868. 6. TPM MAT/03/2021. A2/B2 (Proton Pump Inhibitors oral units) Market. 7. Generics Dictionary. [online] Available at: http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_name_eq%5D=OMEPRAZOLE&q%5Bmanufacturer_ name_cont%5D=&q%5Bbrand_cont%5D= [Accessed 27 May 2021].

S2 RapAcid capsule. Each capsule contains 10 mg omeprazole. Reg. No.: A39/11.4.3/0466. S2 Adco Omeprazole 20 capsule. Each capsule contains 20 mg omeprazole. Reg. No.: 37/11.4.3/0228.

For full prescribing information, please refer to the professional information approved by SAHPRA (South African Health Products Regulatory Authority).

References: 1. Kalaitzakis E, Björnsson E. A review of esomeprazole in the treatment of gastroesophageal reflux disease (GERD). Therapeut & Clin Risk Management 2007;3(4):653-663. 2. Scheiman JM, AdcockND,Ingram Limited.

Reg. No.: 1949/034385/06.

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Yeomans Talley NJ, et al. Prevention of Ulcers

by Esomeprazole1inNew At-Risk Patients Using Non-Selective NSAIDs COX-2 Inhibitors. Am J Gastroenterol 2006;101:701-710. 3. Data on File: Ranbaxy ® Nexipraz (SA) (Pty) Ltd.11S4635 20www.adcock.com Gastro-resistant tablets. Reg. No. 45/11.4.3/0125. Each gastro-resistant tablet contains esomeprazole magnesium 20,7 mg equivalent to esomeprazole 20 mg. Contains Tel.: +27 0000. sugar.

S4 Nexipraz® 40 Gastro-resistant tablets.Reg. No. 45/11.4.3/0126. Each gastro-resistant tablet contains esomeprazole magnesium 41,4 mg equivalent to esomeprazole 40 mg. Contains sugar. For full 2019110110171460 prescribing information please refer to the package insert approved by the medicines regulatory authority. Applicant: Ranbaxy (SA) (Pty) Ltd, a SUN PHARMA company, Ground Floor, Tugela House, Riverside Office Park, 1303 Heuwel Avenue, Centurion, 0046.Tel: +27 12 643 2000. Fax: +27 12 643 2001. www.sunpharma.com.

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MEDICAL CHRONICLE 33 MEDICAL CHRONICLE | MAY 2017 25

CLINICAL | GASTROENTEROLOGY GASTROENTEROLOGY Focus

Crohn’s marker improves outcomes

A research group led by the Technical University of Munich (TUM) has discovered a marker at a microscopic level, which can be used to identify patients that show a high probability of suffering from an inflammation recurrence in the immediate future.

I

NTESTINAL STEM CELL metabolism is facilitated by mitochondria – the in-cell power plants.

Chronic inflammation processes inhibit the

has discovered this connection by analysing intestinal epithelial cells of Crohn’s disease patients and comparing them to mouse model findings.

cells’ metabolism and lead to functional loss of these stem cells. In collaboration with the Helmholz Zentrum München and the Université de Paris, a TUM research team

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PREDICTING CROHN’S DISEASE RECURRENCE The study showed that microscopic alterations in stem cell niche were particularly prevalent in those patients who showed symptoms of a relapse of inflammation after six months.“These changes in the stem cell niche are a very early indicator for the start of inflammatory processes. This presents a reasonable starting point for therapeutic intervention,” explained Dirk Haller, Professor for Nutrition and Immunology at TUM.

REMSIMA

®

The first infliximab biosimilar for use in rheumatology, gastroenterology and dermatology 2,3

• Direct and comparable long term efficacy , pharmacokinetics and immunogenicity versus originator in patients with RA inadequately responding to MTX 4,5 • Direct and comparable long term efficacy versus originator in patients with AS 6,7 • Effective in the induction and maintenance of clinical remission in patients with IBD 3 • Generally well tolerated, with a similar safety profile to that of reference infliximab 3

Rheumatoid Arthritis

Ankylosing Spondylitis

Psoriatic Arthritis

Ulcerative Colitis

Crohn’s Disease

RESTORING STEM CELL FUNCTION In both human patients and mouse models, alterations in Paneth and stem cells coincided with decreased mitochondria functionality. Knowing that a lowered mitochondrial respiration leads to alterations in the stem cell niche, the researchers used dichloroacetate (DCA), a substance applied in cancer therapy leading to an increase in mitochondrial respiration.

The shift in cellular metabolism induced

by DCA was able to restore the intestinal stem cell functionality of mice suffering from inflammation, as demonstrated in intestinal organoids, organ-like structures cultured ex vivo.

Psoriasis

Extending the access of biological therapy to more patients with autoimmune disorders 2,3,8

THE INTERRELATED ROLE OF STEM AND PANETH CELLS Stem cells are indispensable for the maintenance and regeneration of tissues.

Intestinal stem cells inside the intestines are intermingled with so-called Paneth cells, which are responsible for the local immune defence and for creating an environment in which the stem cells can prosper, thus termed guardians of the stem cell niche.

Patients suffering from Crohn’s disease have fewer Paneth cells and furthermore, these are limited in their functionality. The research group examined the causes for alterations in Paneth cells and attempted to determine the importance of stem cell metabolism in this context. In addition to mouse studies, the researchers analysed intestinal biopsies from Crohn’s disease patients, characterising the stem cell niche meticulously. After six months, the patients’ intestines were examined again endoscopically focusing on finding signs of inflammation.

A biological within reach

*Approved by EMA in September 2013 and FDA in April 2016. 9 AS = ankylosing spondylitis; EMA = European Medicines Agency; FDA = US Food and Drug Administration; IBD = inflammatory bowel disease; MTX = methotrexate; RA = rheumatoid arthritis References: 1. IMS Market data. May 2020. Data on File. 2. Braun J, Kudrin A. Switching to biosimilar infliximab (CT-P13): Evidence of clinical safety, effectiveness and impact on public health. Biologicals 2016;44:257-266. 3. Blair HA, Deeks ED. Infliximab Biosimilar (CT-P13; Infliximab-dyyb): A Review in Autoimmune Inflammatory Diseases. BioDrugs 2016;30:469–480. 4. Yoo DH, Racewicz A, Brzezicki J, Yatsyshyn R, Arteaga ET, Baranauskaite A, et al. A phase III randomized study to evaluate the efficacy and safety of CT-P13 compared with reference infliximab in patients with active rheumatoid arthritis: 54-week results from the PLANETRA study. Arthritis Res Ther. 2016;18:82. doi: 10.1186/s13075-016-0981-6. 5. Yoo DH, Prodanovic N, Jaworski J, Miranda P, Ramiterre E, Lanzon A, et al. Efficacy and safety of CT-P13 (biosimilar infliximab) in patients with rheumatoid arthritis: comparison between switching from reference infliximab to CT-P13 and continuing CT-P13 in the PLANETRA extension study. Ann Rheum Dis. 2017;76:355–363. 6. Park W, Yoo DH, Jaworski J, Brzezicki J, Gnylorybov A, Kadinov V, et al. Comparable long-term efficacy, as assessed by patient-reported outcomes, safety and pharmacokinetics, of CT-P13 and reference infliximab in patients with ankylosing spondylitis: 54-week results from the randomized, parallel-group PLANETAS study. Arthritis Res Ther. 2016;18:25. doi: 10.1186/s13075-016-0930-4. 7. Park W, Yoo DH, Miranda P, Brzosko M, Wiland P, Gutierrez-Ureña S, et al. Efficacy and safety of switching from reference infliximab to CT-P13 compared with maintenance of CT-P13 in ankylosing spondylitis: 102-week data from the PLANETAS extension study. Ann Rheum Dis 2017;76:346–354. 8. Goll GL, Jørgensen KK, Sexton J, Olsen IC, Bolstad N, Haavardsholm EA, et al. Long-term efficacy and safety of biosimilar infliximab (CT-P13) after switching from originator infliximab: open-label extension of the NOR-SWITCH trial. J Intern Med. 2019;285(6):653-669. 9. Gabbani T, Deiana S, Annese V. CT-P13: design, development, and place in therapy. Drug Design, Development and Therapy 2017:11 1653–1661.

THERAPEUTIC APPROACH “These findings point to a new therapeutic approach for prolonging the inflammationfree remission phases of Crohn’s disease,” said Eva Rath, scientist at the TUM School of Life Sciences Weihenstephan and coauthor of the study.

S4 REMSIMA® powder for concentrate for solution for infusion. Each vial contains: 100 mg infliximab. Reg. No. 52/30.1/0309.

For full prescribing information refer to the package insert approved by the medicines regulatory authority. Adcock Ingram Limited.

Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021. Tel. + 27 11 635 0000. www.adcock.com 202006261041764

Source: University of Munich

34 MEDICAL CHRONICLE 41108 Remsima advert 'A4'.indd 1

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GASTROENTEROLOGY Focus

RESOLVE THE REFLUX Choose...

TOPZOLE®: SOUTH AFRICA’S NO.1 PPI PANTOPRAZOLE*1 • Effective GORD symptom relief2 • Daily pantoprazole maintenance therapy for severe acid-peptic disease is effective and well tolerated for up to 15 years3 • Low potential for drug interactions4 • TOPZOLE® 20 mg is suitable for on-demand use, once daily, when required5 DOSAGE Duodenal ulcer

OD for 2-4 weeks

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OD for 4 weeks. May be repeated for another 4 weeks if complete healing has not been achieved within the first 4 weeks

Long-term management and prevention of relapse of GORD

20 mg OD. May be increased to 40 mg OD should relapse occur, to be reduced to 20 mg OD once healing of relapse has been achieved

*in relation to sales value; GORD = Gastro-oesophageal reflux disease; OD = Once daily; PPI = Proton pump inhibitor References: 1. IMS Data, MAT Value 01/2021. 2. Scholten T, Gatz G, Hole U. Once-daily pantoprazole 40 mg and esomeprazole 40 mg have equivalent overall efficacy in relieving GERD-related symptoms.

Aliment Pharmacol Ther. 2003;18:587-594. 3. Brunner G, Athmann C, Scheider A. Long-term,open-label trial: safety and efficacy of continuous maintenance treatment with pantoprazole for up to 15 years in severe acid-peptic disease. Aliment Pharmacol Ther. 2012;doi:10.1111/j.1365-2036. 2012.05106.x:1-11. 4. Blume H, Donath F, Warnke A, Schug BS. Pharmacokinetic Drug Interaction Profiles of Proton Pump Inhibitors. Drug Safety. 2006;29(9):769-784. 5. Topzole Approved Package Insert. Takeda (Pty) Ltd. 2012 September 14.

S4 TOPZOLE® 20. Reg. No. 38/11.4.3/0061. Each enteric-coated tablet contains 20 mg pantoprazole. S4 TOPZOLE® 40. Reg. No. 38/11.4.3/0060. Each enteric-coated tablet contains 40 mg pantoprazole. For full prescribing information, refer to the Professional Information approved by the Medicines Regulatory Authority.

TAKEDA (Pty) Ltd. Reg. No.: 1982/011215/07. Building A, Monte Circle, 64 Montecasino Boulevard, Fourways, 2191, South Africa. Tel: +27 (0) 514 3000. Fax: +27 (0) 11 514 3001. Marketed by Adcock Ingram Limited Reg. No.: 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Tel: +27 (0) 11 635 0000. www.adcock.com. 202103161093428. C-APROM/ZA/PTZ/0026

MEDICAL CHRONICLE 35

ONLINE CPD Focus GASTROENTEROLOGY

Beating diarrhoea

This is a summary of a CPD-accredited article available on www.medicalacademic.co.za

with probiotics

The beneficial gastrointestinal effects of probiotics are well-documented, especially the way they bolster the gut microbiome. Are probiotics, and the strain Saccharomyces boulardii CNCM I-745 in particular, a great supplemental treatment for diarrhoea?

U

SING PROBIOTICS TO COMBAT DIARRHOEA According to the World Health Organization (WHO) and UNICEF, there are about two billion cases of diarrhoeal disease worldwide every year, and 1.9 million

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children younger than five years of age perish from diarrhoea each year, mostly in developing countries. This amounts to 18% of all the deaths of children under the age of five and means that more than 5000 children are dying every day because of 1

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diarrheal diseases. Of all child deaths from diarrhoea, 78% occur in the African and South-East Asian regions. Diet regulation, oral rehydration salt and other methods are the routine treatment for controlling the development of diarrhoea, which may lead to

intestinal dysbacteriosis due to its prolonged effective time of stopping diarrhoea. Studies have shown that infantile diarrhoea not only cause acidbase imbalance in the intestine, but also affect the respiratory systems of children.

Diarrhoea is a common adverse effect of systemic antibiotic treatment. Antibioticassociated diarrhoea (AAD) occurs in 5% to 39% of patients, from the beginning and up to two months after the end of treatment.

Any type of antibiotics can cause AAD. Aminopenicillins, cephalosporins, and clindamycin that act on anaerobes are associated with a high risk of AAD. The symptoms range from mild and selflimiting diarrhoea to severe diarrhoea, the latter particularly in Clostridium difficile infections. Many studies have suggested that probiotics are useful in the prevention of AAD, especially in a paediatric population.

With respect to probiotics for the prevention of paediatric diarrhoea and antibioticassociated diarrhoea, it has been described that probiotics can restore microbial balance and thus inhibit the proliferation of pathogens such as C. difficile, acting as both preventive and treatment.

Among the numerous impacts of antibiotics on the gut microbiome are reductions in microbial taxonomic richness, diversity, and evenness in the GI tract.

Those drastic changes result in a depletion of the normal gut bacterial residents and opportunities for colonisation by pathogens such as Clostridium difficile.

SACCHAROMYCES BOULARDII Saccharomyces boulardii powder is a biological antidiarrheal agent. A recent study showed that Saccharomyces boulardii had a potent preventive effect on antibioticassociated diarrhoea, acute infection, irritable bowel syndrome and nonspecific diarrhoea. Its main active ingredient is lyophilized and viable Saccharomyces boulardii CNCM I-745, and it is the first choice of drugs in the treatment of infantile diarrhoea.

CONTAINS THE PATENTED LIVING YEAST, SACCHAROMYCES BOULARDII CNCM I-745

INDICATED IN AAD AND NON-SPECIFIC ACUTE DIARRHOEA

ONE CAPSULE TWICE A DAY OR AS PRESCRIBED

SUITABLE FOR USE IN INFANTS, CHILDREN, ADULTS AND IN THE ELDERLY

S. boulardii is naturally resistant to antibiotics 2

Reference: Reference: 1. Source: Internal calculations via IQVIA database - MIDAS 2019 ATC: A7F - ANTIDIARR MICRO-ORGANISM. 2. Czerucka D, Piche T, Rampal P. Review article: yeast as probiotics - Saccharomyces boulardii. Aliment Pharmacol Ther. 2007;26(6):767 to 778

S0 INTEFLORA 250 (capsule). Ref. No.: T194 (Act 101/1965).

Each capsule contains 250 mg lyophilised cells of Saccharomyces boulardii CNCM I-745®. For full prescribing information refer to the professional information approved by the medicines regulatory authority (03/1985).

Trademarks are owned by or licensed to the Aspen Group of companies. © 2020 Aspen Group of companies or its licensor. All rights reserved. Marketed by Aspen Pharmacare for Pharmacare Limited. Co. Reg. No.: 1898/000252/06. Healthcare Park, Woodlands Drive, Woodmead, 2191. ZAR-SAB-07-20-00007 08/20

CONCLUSION Probiotics have clear utility in cases of diarrhoea and is particularly effective as a way to mitigate AAD. Among probiotic strains, the yeast Saccharomyces boulardii is perhaps most effective at targeting the symptoms of AAD and Clostridium difficile-associated diarrhoea.

Probiotics have a powerful protective action within the GI tract that acts as a counterweight and/or preventative measure to the symptoms of diarrhoea.

References available on request.

22 NOVEMBER 2020 | MEDICAL CHRONICLE 36 MEDICAL CHRONICLE

GASTROENTEROLOGY Focus

CLINICAL | GASTROENTEROLOGY

A first for SA

Minimally invasive procedure for haemorrhoids There is a painless new option available for patients who suffer from debilitating haemorrhoids.

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NEW MINIMALLY INVASIVE embolisation procedure to treat haemorrhoidal disease — a very common medical condition that impacts the lives of many South Africans — was recently performed for the first time at Netcare hospitals in Johannesburg and Cape Town, and is now being offered as a standard treatment option at these facilities for appropriate cases.

Interventional radiologists Dr Gary Sudwarts and Dr Maja Wojno successfully performed the newly introduced rectal artery embolisation procedures at Netcare Park Lane Hospital and at UCT Private Academic Hospital (UCTPAH) recently. Dr Sudwarts says that the intervention has shown most promising results internationally in the treatment of

haemorrhoids since it was first introduced overseas in recent years.

“This approach, which has a number of advantages over the surgical removal of haemorrhoids, including that it is painless and recovery times are greatly reduced, is showing itself to be an invaluable new treatment option for haemorrhoidal disease patients in South Africa,” said Dr Sudwarts.

“Pleasing outcomes have been achieved globally with the minimally invasive embolisation procedure, which involves blocking the blood vessels that are supplying the haemorrhoids with blood, causing them to shrivel and die. The procedure is safe and has achieved a meaningful reduction in symptoms and improved quality of life for patients,” noted Dr Sudwarts and Dr Sudwarts, who practises at Netcare Park

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38 MAY 2019 | MEDICAL CHRONICLE

Dr Maja Wojno and Dr Gary Sudwarts

Lane Hospital in Johannesburg and UCT Private Academic Hospital in Cape Town. He is now offering the procedure as a standard treatment option to appropriate patients.

Haemorrhoids may become debilitating and a medical problem when they are persistently swollen, causing pain, bleeding and/or severe itching in the anus. It is estimated that half of the population will experience the condition at some point in their lives.

Specialists will commonly first treat haemorrhoid disease using a rubber band over the enlarged haemorrhoidal vein.

Eventually, however, some patients require surgical removal of haemorrhoids While most cases of haemorrhoidal disease are not serious and symptoms often go away on their own, or can be easily managed through an improved diet and lifestyle and the use of prescribed and over-the-counter medicine, they may in some cases swell significantly and cause incapacitating symptoms. Such cases may require surgical intervention particularly in patients in whom bleeding is the main symptom.

“Specialists will commonly first treat haemorrhoid disease using a rubber band over the enlarged haemorrhoidal vein.

Eventually, however, some patients require surgical removal of haemorrhoids.

“Haemorrhoidectomy has traditionally been a standard treatment approach

for more serious cases of this condition, although ultrasound guided interventions and other approaches are also available today. As the anus is a highly sensitive area, the haemorrhoidectomy can be extremely painful and recovery can take two weeks or more. In addition, in some cases the haemorrhoids can re-occur.

“On the other hand, the embolisation procedure is a safe day procedure used in cases of severe and persistent haemorrhoid disease causing uncomfortable and debilitating symptoms, and may also be considered for patients for whom surgery is not an option due to other co-morbidities.

Patients are discharged home the day of the procedure, and tend to recover much quicker and report little or no post-operative pain,” said Dr Sudwarts.

Haemorrhoid disease is often linked with persistent constipation or diarrhoea, obesity, poor posture, too much sitting, previous surgery on the rectum, cancer and sometimes pregnancy. External haemorrhoids protrude from the anus and may need to be pushed back in after a stool has been passed, and can be prone to secondary skin infections.

According to Dr Sudwarts, persistently swollen haemorrhoids can cause severe discomfort and pain. In some cases, they may be a symptom of a more serious underlying medical condition. Medical practitioners need to investigate the cause of rectal bleeding or if there is an underlying condition that is causing the haemorrhoids to enlarge.

“While there remains a need for studies to assess the long-term effectiveness of the haemorrhoidal embolisation technique, the fact that it is safe, painless and is showing good short-term results, is making it an increasingly popular option internationally.

We are excited to be offering the new minimally invasive option in South Africa,” concluded Dr Sudwarts.

MEDICAL CHRONICLE 37