Gastroenterology Today Autumn 2019

Volume 29 No. 3
Autumn 2019
Gastroenterology Today
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In this issue
An unusual case of oesophagitis
Assessment of thyroid profile in
patients with fissure in ANO

Life feels good
when Crohn’s is
under control 1,2
Entocort ® CR is indicated for the induction
of remission in adults with mild to moderate
Crohn’s disease affecting the ileum and/or
the ascending colon 3
Oral modified-release budesonide preparations are formulated to target specific types of
inflammatory bowel disease. To ensure your patient receives a budesonide indicated for Crohn’s
disease, prescribe Entocort ® CR by brand.
ENTOCORT CR 3mg Capsules (budesonide) - Prescribing
Information
Please consult the Summary of Product Characteristics (SmPC) for full
prescribing Information
Presentation: Hard gelatin capsules for oral administration with an
opaque, light grey body and an opaque, pink cap marked CIR 3mg in
black radial print. Contains 3mg budesonide. Indications: Induction of
remission in patients with mild to moderate Crohn’s disease affecting the
ileum and/or the ascending colon. Induction of remission in patients with
active microscopic colitis. Maintenance of remission in patients with
microscopic colitis. Dosage and administration: Active Crohn’s disease
(Adults): 9mg once daily in the morning for up to eight weeks. Full effect
achieved in 2-4 weeks. When treatment is to be discontinued, dose
should normally be reduced in final 2-4 weeks. Active microscopic colitis
(Adults): 9mg once daily in the morning. Maintenance of microscopic
colitis (Adults): 6mg once daily in the morning, or the lowest effective
dose. Paediatric population: Not recommended. Older people: No
special dose adjustment recommended. Swallow whole with water. Do
not chew. Contraindications: Hypersensitivity to the active substance or
any of the excipients. Warnings and Precautions: Side effects typical of
corticosteroids may occur. Visual disturbances may occur. If a patient
presents with symptoms such as blurred vision or other visual
disturbances they should be considered for referral to an
ophthalmologist for evaluation of the possible causes. Systemic effects
may include glaucoma and when prescribed at high doses for
prolonged periods, Cushing’s syndrome, adrenal suppression, growth
retardation, decreased bone mineral density and cataract. Caution in
patients with infection, hypertension, diabetes mellitus, osteoporosis,
peptic ulcer, glaucoma or cataracts or with a family history of diabetes
or glaucoma. Particular care in patients with existing or previous history
of severe affective disorders in them or their first degree relatives.
Caution when transferring from glucocorticoid of high systemic effect to
Entocort CR. Chicken pox and measles may have a more serious course
in patients on oral steroids. They may also suppress the HPA axis and
reduce the stress response. Reduced liver function may increase
systemic exposure. When treatment is discontinued, reduce dose over
last 2-4 weeks. Concomitant use of CYP3A inhibitors, such as
ketoconazole and cobicistat-containing products, is expected to
increase the risk of systemic side effects and should be avoided unless
the benefits outweigh the risks. Excessive grapefruit juice may increase
systemic exposure and should be avoided. Patients with fructose
intolerance, glucose-galactose malabsorption or sucrose-isomaltase
insufficiency should not take Entocort CR. Monitor height of children who
use prolonged glucocorticoid therapy for risk of growth suppression.
Interactions: Concomitant colestyramine may reduce Entocort CR
uptake. Concomitant oestrogen and contraceptive steroids may
increase effects. CYP3A4 inhibitors may increase systemic exposure.
CYP3A4 inducers may reduce systemic exposure. May cause low
values in ACTH stimulation test. Fertility, pregnancy and lactation:
Only to be used during pregnancy when the potential benefits to the
mother outweigh the risks for the foetus. May be used during breast
feeding. Adverse reactions: Common: Cushingoid features,
hypokalaemia, behavioural changes such as nervousness, insomnia,
mood swings and depression, palpitations, dyspepsia, skin reactions
(urticaria, exanthema), muscle cramps, menstrual disorders.
Uncommon: anxiety, tremor, psychomotor hyperactivity. Rare:
aggression, glaucoma, cataract, blurred vision, ecchymosis. Very rare:
Anaphylactic reaction, growth retardation. Prescribers should consult
the summary of product characteristics in relation to other adverse
reactions. Marketing Authorisation Numbers, Package Quantities and
basic NHS price: PL 36633/0006. Packs of 100 capsules: £84.15. Legal
category: POM. Marketing Authorisation Holder: Tillotts Pharma UK
Ltd, The Stables, Wellingore Hall, Wellingore, Lincoln, LN5 0HX. Date of
preparation of PI: November 2018
Adverse events should be reported. Reporting forms
and information can be found at https://yellowcard.
mhra.gov.uk. Adverse events should also be reported
to Tillotts Pharma UK Ltd. Tel: 01522 813500.
References: 1. Greenberg GR, et al. N Engl J Med 1994; 331: 836-841.
2. Rezaie A, et al. Cochrane Database Syst Rev 2015; 6: CD000296.
3. Entocort ® CR 3mg Capsules – Summary of Product Characteristics.
November 2018.
Date of preparation: January 2019. PU-00237.

CONTENTS
CONTENTS
5 EDITORS COMMENT
Matthew’s Perspective:
6 CASE REPORT An unusual case of oesophagitis
8 FEATURE Assessment of thyroid profile in patients with
fissure in ano in the South Indian population
15 NEWS
28 BSG POSTERS
30 COMPANY NEWS
COVER STORY
What approach has 18 Week Support taken with
regards to building an expert insourcing team?
What approach has 18 Week Support
taken with regards to building an
expert insourcing team?
Gastroenterology Today
This issue edited by:
Andy Poullis
c/o Media Publishing Company
Media House
48 High Street
SWANLEY, Kent BR8 8BQ
Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. He believes it starts with recruiting the
best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well
above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data
is an excellent quality indicator, we now want to go a step beyond that and monitor the Non-Technical skills (NTS) of each
clinician as well. We now know that NTS plays an important role in safe and effective team performance. Therefore, in our
quest to develop excellent teams who deliver a world-class service, we must ADVERTISING focus on NTS’. & CIRCULATION:
Media Publishing Company
Tammy and Lisa’s Perspective:
Media House, 48 High Street
Tammy Kingstree is Lead Nurse for Endoscopy.
SWANLEY, Kent, BR8 8BQ
‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from
our senior nurse coordinators who are trained to manage the patient pathway, Tel: manage 01322 a team 660434 of staff Fax: they may 01322 not know 666539
and to deal effectively with any issues which may arise on the day’. E: info@mediapublishingcompany.com
www.MediaPublishingCompany.com
Lisa Phillips is Lead Nurse for Endoscopy.
‘The team objectives are clear. Excellent patient experience and good patient outcomes. Because the objectives are clear,
team cohesion and focus are exceptionally good. It therefore shouldn’t matter PUBLISHING that we are in an unfamiliar DATES: endoscopy unit,
the service should be seamless. If it isn’t, we do not stop until we get it right. February, June and October.
If you have an excellent NHS record and want to help clear NHS waiting list backlogs, reduce RTT waiting times and provide
high-quality patient care, get in touch by calling on 020 3892 6162 or email COPYRIGHT:
Gastro.Recruitment@18weeksupport.com
Media Publishing Company
Media House
48 High Street
SWANLEY, Kent, BR8 8BQ
PUBLISHERS STATEMENT:
The views and opinions expressed in
this issue are not necessarily those of
the Publisher, the Editors or Media
Publishing Company.
Matthew’s Perspective:
Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology.
He believes it starts with recruiting the best clinicians. ‘At 18 Week Support we set
the bar very high. We only recruit clinicians whose JAG performance data is well
above the national standards. In addition, we monitor each clinician’s KPIs while
they work with 18 WS. While the JAG data is an excellent quality indicator, we
now want to go a step beyond that and monitor the Non-Technical skills (NTS) of
each clinician as well. We now know that NTS plays an important role in safe and
effective team performance. Therefore, in our quest to develop excellent teams who
deliver a world-class service, we must focus on NTS’.
Tammy and Lisa’s Perspective:
Tammy Kingstree is Lead Nurse for Endoscopy.
‘It is extremely important that there are good working relationships within the team.
This starts with strong leadership from our senior nurse coordinators who are trained
to manage the patient pathway, manage a team of staff they may not know and to
deal effectively with any issues which may arise on the day’.
Lisa Phillips is Lead Nurse for Endoscopy.
‘The team objectives are clear. Excellent patient experience and good patient
outcomes. Because the objectives are clear, team cohesion and focus are exceptionally
good. It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit, the
service should be seamless. If it isn’t, we do not stop until we get it right.
If you have an excellent NHS record and want to help clear NHS waiting list backlogs,
reduce RTT waiting times and provide high-quality patient care, get in touch by
calling on 020 3892 6162 or email Gastro.Recruitment@18weeksupport.com
Next Issue Spring 2020
Subscription Information – Autumn 2019
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GASTROENTEROLOGY TODAY - AUTUMN 2019
3

TVEG & GENIE Presents
A STUDY DAY
Sponsored by
7th December 2019
The specialised area of Gastroenterology/Endoscopy is an area where
we pride ourselves with working alongside the British Society of
Gastroenterology (BSG).
The BSG aims to provide quality improvement to create the same level
of care for patients and provide high standards therefore protocols
and policies are updated on a regular basis.
So even when working for a NHS Trust or a company like 18 Week
Support, all Endoscopy units adhere to BSG, JAG (Joint Advisory
Service) and GRS (Global Rating Score). With this in mind, staff in
either a private sector or the NHS needs to be updated. The whole
team from the Consultants to Clinical Nurse Endoscopists and the
endoscopy nurses require these resources to keep updated, therefore
the most efficient way is education.
Education is at the forefront of Health especially with the changes
in recent times, such as the Nursing and Midwifery Council
revalidation process and the Darzi report and recommendations. It’s
vital to support our workforce with up-to-date events to provide high
quality education.
The education group TVEG (Thames Valley Endoscopy Group) and
GENIE (Gastroenterology Endoscopy Nurses in Essex) have been
running for over 25yrs, merging together to cover a large area of
Essex, London and the surrounding areas. We have provided annual
study days for Endoscopy Nurses and of late Specialist and Nurse
Endoscopists. So that we can capture all regions, in the past we
have held studies in varying trusts. Education is vital to provide high
quality services and have members of the team working with up to
date knowledge and endeavor to make across all NHS trusts to the
same standards. Therefore, it’s with great privilege this year to team
up with 18 Week Support to give another outstanding study day.
We have grown immensely over the years and with their continuing
commitment, we hope to get NHS and the 18 Week Support staff to
provide an even higher quality service to NHS trusts.
Holding the study day on a Saturday opens it up for all to attend and
everyone is grateful for the speakers giving up their time.
The program for this event will be released in November, tickets will
be sold via Eventbrite, feel free to attend. Lunch and Refreshments will
be provided
We will provide expert advice on latest updates, tips and tricks
with hands on techniques and, as always popular, we will have live
Endoscopy from Professor of Gastroenterology Prof Mathew Banks
and Clinical Nurse Endoscopist Sr Sara Brogden.
Could you please send any enquires to sara.brogden@nhs.net
Delegates must all be working within Endoscopy/Gastroenterology
and the attendance will be capped at 125- 130 delegates.
This study day is run as a charity. Please note, if you already work shifts
with 18 Week Support and visit their stand or if you successfully apply
to work with 18 Week Support on the day and complete a shift by the
31st of March 2020 you will be able claim your attendance fee back.
Yours sincerely,
Sara E M Brogden
(Chair of TVEG & GENIE)
About you
If you have an excellent NHS record and want to help clear NHS
waiting list backlogs, reduce RTT waiting times and provide highquality
patient care, get in touch by calling on 0203 966 9081
or email us at recruitment@18weeksupport.com
Our mission: giving up-to-date education, providing current criteria,
quality and commitment to all. 18 Week support will help to provide
this, showing that we can continue improving care and support to our
health professional patients, and trusts and continue to work with the
key points of BSG, JAG and GRS.
This year the study day will be held on Saturday 7th December 2019
at the 1st Floor Educational Centre University College Hospital, 250
Euston Road, NW1 2PG
www.18weeksupport.com
London
3rd Floor, 19-21 Great Tower Street
London | EC3R 5AR | 020 3869 8790

EDITORS COMMENT
EDITORS COMMENT
“If unsure
on the
suitability of
an article or
case report
then please
feel free to
contact the
editorial
office so
we can give
advice.”
Gastroenterology Today going from strength to strength
I am pleased to be able to bring a range of reports, features and news in this edition
of GT. We have had an increase in submitted articles enabling us to bring a range of
articles.
Another case report from St George’s reminding us all that occasionally reflux symptoms
have slightly more to them....
An interesting report from India reminds us that, in the population studied, systemic disease
still can manifest with local/bowel symptoms.
Our news section highlights a number of dynamic initiatives in the world of
gastroenterology.
At GT we want to fully support all aspiring gastroenterologists and are also keen to support
submissions. If unsure on the suitability of an article or case report then please feel free
to contact the editorial office so we can give advice. We accept a wide variety of materials
from personal view, mini-reviews, case reports, studies to news of important GI related
events.
We are pleased to announce that we will be moving back to 4 publications a year due to
interest in the journal and the volume of work submitted.
I think I have achieved the impossible - an editorial without reference to the NHS pension
disaster or Brexit!!
Andy Poullis
St George’s Hospital, London
GASTROENTEROLOGY TODAY - AUTUMN 2019
5

CASE REPORT
AN UNUSUAL CASE OF
OESOPHAGITIS
K Punjabi, V Vakeeswarasarma, A Poullis
Department of Gastroenterology, St George’s Hospital
GASTROENTEROLOGY TODAY - AUTUMN 2019
6
Abstract
We report a case of a patient with multisystem systemic lupus
erythematosus (SLE), requiring immunosuppressant therapy, who
presented with symptoms of gastro-oesophageal reflux a year after
starting Mycophenolate Mofetil (MMF). An initial gastroscopy showed
severe oesophagitis with ulceration with oesophageal biopsies
showing chronic inflammation. Treatment was initiated with high dose
proton pump inhibitor therapy and the addition of a histamine receptor
antagonist when no endoscopic improvement was identified. Repeat
oesophageal biopsies suggested a possible infective element to the
gastro-oesophageal reflux. Polymerase chain reaction (PCR) detected
EBV DNA in serology (at 160 IU/ml) and on oesophageal biopsies.
A diagnosis of EBV oesophagitis was made and treated with a one
month course of Valcyclovir. On initiation with this treatment the reflux
symptoms rapidly resolved. Following the diagnosis, the dose of
MMF was reduced. Further repeat PCR on blood and biopsy samples
have returned negative. Oesophageal manifestation of EBV are rarely
reported and should be considered in patients with oesophageal
ulceration at endoscopy not responding to anti-reflux medications.
Diagnosis is most sensitive with polymerase chain reaction testing
rather than cellular pathological examination or serological markers to
allow for prompt management.
Case History
A 43 year old woman was initially referred to gastroenterology clinic
for symptoms of indigestion and burning reflux one year after initiating
Mycophenolate Mofetil (MMF). She was under various speciality teams
for SLE with multisystem involvement, including Sjogren’s syndrome,
interstitial lung disease, nephrotic syndrome, and neurologic SLE.
Initially she was managed on azathioprine but changed to MMF after
renal biopsy confirmed SLE membranous nephritis, which was titrated
to 1.5g twice a day and a background low dose prednisolone was
continued. Her initial gastroscopy showed severe oesophagitis with
ulceration and biopsies showed chronic inflammation so was started
on high dose omeprazole at 40mg twice a day, which only partially
improved the reflux symptoms. A repeat gastroscopy showed severe
oseophagitis, so her therapy was changed to esomprazole 40mg
once a day and ranitidine 150mg once a day. Biopsies at follow up
suggested it was more than simple severe gastro-oesophageal reflux
and suggestive of an infective aetiology.
A serological viral screen identified a reactive HSV-1 IgG, suggesting
a recent HSV infection, but a negative HIV, EBV IgM and CMV. Viral
polymerase chain reaction (PCR) identified 160 IU/ml of EBV DNA.
PCR for EBV DNA carried out on oesophageal biopsies confirmed the
diagnosis of EBV oesophagitis a year after initial presentation and the
patient was initiated on valcyclovir 1g three times a day for one month.
On this treatment the reflux symptoms gradually resolved.
At endoscopic follow up there was significant improvement to the
oesophageal inflammation and biopsies returned negative for EBV DNA.
At clinical follow up she remains well.
Discussion
Infective oesophagitis in a healthy individual is a relatively rare condition.
However, the prevalence rises in certain high-risk populations, such
as those with a compromised immune system. Infection could also
be secondary to other causes, such as diabetes mellitus, malignancy,
gastro-oesophageal reflux disease (GORD) or chronic corticosteroid
use (1).
Causes of infective oesophagitis can be sub-divided into bacterial, viral
and fungal. Risk factors can range from immunosuppressive conditions
or chemotherapies, neutropenia, antimicrobial therapy and HIV infection
(2,3). Infectious agents can get in contact with the oesophageal mucosa
either by direct contact, through lymphatics and vascular systems, or by
direct extension from adjacent mediastinal structures (2).
The most common cause is the fungal infection Candida albicans.
Candida is a dimorphic yeast and usually invades tissue by the
formation of hyphae in the distal third of the oesophagus, leaving behind
superficial yellow-white plaques. This infection is likely to be found in
patients with acquired immunodeficiency syndrome (3) and steroid use.
Bacterial oesophagitis is less common than fungal and is usually found
in sites of oesophageal mucosal disruption, likely secondary to acid
reflux (4). As mentioned, this incidence increases when a person is
immunocompromised. Normal oesophageal flora consists of grampositive
bacteria, commonly Streptococci viridans. However, this can
change to gram-negative due to reflux, leading to more complications
(5). In immunocompromised patients, bacterial infection can be
polymicrobial, and in some cases of HIV patients, mycobacterial.
Cytomegalovirus (CMV) is one of the commonest viral causes for
infective oesophagitis, usually occurring in patients post solid organ
transplant (1). These patients are often given prophylactic treatment,
however despite this, there is still a proportion that develop delayed
onset CMV infection. Herpes Simplex Virus infection type 1 (HSV-
1) is typically the cause over HSV-2 for oesophageal infection. On
endoscopy, diagnostic raised edge ulcers are seen, forming a punched

CASE REPORT
out or volcano-like appearance. PCR on biopsy samples can confirm
the diagnosis (6).
In this case, EBV was the cause of the oesophagitis. EBV is thought to
activate immune-mediated mechanisms which ultimately leads to tissue
damage (7). During investigation, it is important not to solely rely on a
standard peripheral blood exam and routine histopathology, as this may
lead to an incorrect diagnosis (8). Diagnosis can be confirmed with PCR
on biopsy specimens. On endoscopy, there is ulceration, which differs
from HSV as the ulcers seen are usually deeper, more linear and located
in the mid-oesophagus. The main management is with acyclovir therapy,
which should lead to resolution of the oesophagus confirmed with a
repeat endoscopy (9).
Oesophagitis due to EBV infection should be considered in patients
with recurrent symptoms and endoscopic appearance of oesophageal
ulceration. Our case identifies the significance of PCR testing of biopsy
samples to allow for prompt diagnosis and appropriate management.
References
1. O’Rourke A. Infective oesophagitis. Current Opinion in
Otolaryngology & Head and Neck Surgery. 2015;23(6):459-463.
2. De Prez C. Oesophagites infectieuses. Acta Endoscopica.
2002;32(2):119-123.
3. Asayama N, Nagata N, Shimbo T, Nishimura S, Igari T, Akiyama J et
al. Relationship between clinical factors and severity of esophageal
candidiasis according to Kodsi’s classification. Diseases of the
Esophagus. 2013;27(3):214-219.
4. Radhi J, Schweiger F. Bacterial oesophagitis in an
immunocompromised patient. Postgraduate Medical Journal.
1994;70(821):233-234.
5. Yang L, Francois F, Pei Z. Molecular Pathways: Pathogenesis and
Clinical Implications of Microbiome Alteration in Esophagitis and
Barrett Esophagus. Clinical Cancer Research. 2012;18(8):2138-
2144.
6. Lee B. A rare cause of dysphagia: Herpes simplex esophagitis.
World Journal of Gastroenterology. 2007;13(19):2756.
7. Pape M, Mandraveli K, Sidiropoulos I, Koliouskas D, Alexiou-Daniel
S, Frantzidou F. Unusual Epstein-Barr esophageal infection in an
immunocompetent patient: a case report. Journal of Medical Case
Reports. 2009;3(1):7314.
8. Annaházi A, Terhes G, Deák J, Tiszlavicz L, Rosztóczy A,
Wittmann T et al. Fulminant Epstein–Barr virus esophagitis in an
immunocompetent patient. Endoscopy. 2011;43(S 02):E348-E349.
9. Baehr P, McDonald G. Esophageal infections: Risk factors,
presentation, diagnosis, and treatment. Gastroenterology.
1994;106(2):509-532.
POSTER SUBMISSIONS
If you have submitted a poster to this years BSG
or ENDOLIVE events and would like it published in
Gastroenterology Today please forward a PDF of your
poster to the email address listed below.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com
GASTROENTEROLOGY TODAY - AUTUMN 2019
7

FEATURE
ASSESSMENT OF THYROID PROFILE
IN PATIENTS WITH FISSURE IN ANO
IN THE SOUTH INDIAN POPULATION
Saveetha Institute of Medical and Technical Science, Chennai, India
Madhumitha Prabhakaran, Bharath N, Arcot Rekha
Abstract
Objectives
Keywords: Hypothyroidism, Fissure in ano, Anal fissure,
constipation, thyroid profile, lower gastrointestinal complaints
Background: A precipitating history of constipation is found in
approximately 20% of patients with anal fissures. Hard feces result
in local trauma to the rectal mucosa which in turn secondarily
activates internal anal sphincter hypertonia. As the maximum
resting anal pressure (MRAP) is usually greater than 90 mm Hg
in patients with fissures such hypertonia will compress these end
arteries and cause ischemia of the posterior commissure and
eventually anal fissures. Constipation is one of the classic signs
of hypothyroidism. The most probable pathological reason is the
intestinal edema due to mucopolysaccharide accumulation in
gastrointestinal tissue.
Method: This is a prospective, observational study. We first
identified the male and female patients presenting to the outpatient
department with various lower abdominal complaints. Informed
consent for inclusion in the study was obtained. A thyroid assay
was ordered for all the anal fissure patients who were admitted for
surgical procedures.
1. To determine the incidence of patients with lower gastrointestinal
symptoms attending the surgical outpatient department.
2. To find the incidence of fissure in ano among patients with lower
gastrointestinal symptoms attending the surgical outpatient
department.
3. To analyze the pattern of thyroid profile in patients with fissure in ano
Background
An anal fissure is defined as split in the mucosa extending from the anal
verge to the dentate line. The fissures usually present with pain and
rectal bleeding.
A precipitating history of constipation is found in approximately 20%
of patients with fissure in ano. Hard feces result in local trauma to
the rectal mucosa which in turn secondarily activates internal anal
sphincter hypertonia. Subsequent sphincter spasm leads to further
constipation and a vicious cycle is created. Treatment modalities such
as anal dilatation and internal sphincterotomy aim to break this cycle by
disrupting the internal anal sphincter. [1]
GASTROENTEROLOGY TODAY - AUTUMN 2019
Result: 38.2% of patients with lower gastrointestinal complaints
and 3.6% of the total number of patients presenting to the
surgical OPD were attributed to an anal fissure. The incidence
of hypothyroidism in patients with an anal fissure is 32%. Since
the incidence of hypothyroidism in our study is higher than
the prevalence of hypothyroidism in the general population as
documented by multiple studies in the past, we can conclude that
there is a significant association between hypothyroidism and
development of anal fissures.
Conclusion: By analyzing the thyroid profile in patients with anal
fissures, we found an association between the two entities. This
information can be used to predict and prevent anal fissures in
hypothyroid patients.
Aim
To study the thyroid profile of patients presenting to the surgery
OPD with constipation and a diagnosis of fissure in ano.
The posterior midline of the anus is supplied by end arteries which
pass through the internal anal sphincter before reaching the posterior
commissure. The mean arteriolar blood pressure of the end arteries is
85 mm Hg. As a result, it is thought that the blood flow to this area is
potentially deficient. [2] Fissure in ano patients have maximum resting
anal pressure (MRAP) greater than 90 mm Hg usually. This state of
hypertonia will compress the end arteries, leading to ischemia of the
posterior commissure and finally anal fissures. [3]
Some might say that hypertonia arises secondary to pain. But the
inability to provide relief from the hypertonia by using painkillers
disproves this theory. [4]
Constipation is one of the many classic signs of hypothyroidism.
The pathophysiological changes observed in the digestive tracts
of hypothyroid patients have not been definitely determined, but
according to recent studies, a deficiency of thyroid hormone
weakens the contractions of the muscles that line the digestive
tract. The most probable pathological reason is the accumulation of
mucopolysaccharides, especially hyaluronic acid in the gastrointestinal
8

CHART 2: Diagnosis of female patients presenting with
lower gastrointestinal complaints
FEATURE
tissue leading to intestinal edema. This reduction in the motor activity
delays the intestinal transit time of feces which allows more water
absorption and eventually causes constipation. [5]
This evidence supports the hypothesis that an important etiological
factor of anal fissures is hypothyroidism causing constipation.
Methods
We first identified the male and female patients presenting to the
outpatient department with various lower abdominal complaints like
lower gastrointestinal bleeding, painful defecation, constipation, or
mass descending per rectum. These patients were then diagnosed with
constipation, hemorrhoids, malignancy, fistula, abscess, or fissure in
ano. The fissure in ano patients were further classified as per their age
distribution.
Informed consent for inclusion in the study was obtained. A thyroid
assay was ordered for all the fissure in ano patients who were admitted
for surgical procedures. Patients with TSH values higher than the
reference range or T3/T4 values lower than the reference range were
labeled as hypothyroid.
The prevalence of hypothyroidism is identified in the public population
using previously done studies and compared with the prevalence of
hypothyroidism in our patients with fissure in ano.
TABLE 1: Diagnosis of male patients presenting with lower
gastrointestinal complaints
Constipation 34
Hemorrhoids 43
Malignancy 3
Fistula 11
Abscess 18
Fissure in ano 80
TOTAL 189
Diagnosis of male patients presenting with lower
gastrointestinal complaints
TABLE 2: Age distribution of male patients diagnosed with
fissure in ano
60 years
9%
6%
2
Abscess
Fissure in ano
TOTAL 80
2%
A total of 1497 female patients presented to the surgical OPD during the
study period, of which 127 had lower gastrointestinal complaints.
Result
A total of 3332 patients presented to the Surgical OPD during the study
period, of which 316 presented with lower gastrointestinal complaints.
The incidence of lower gastrointestinal complaints in our surgical OPD
was 9.4%. Of the 316 patients with lower gastrointestinal complaints,
121 were diagnosed with fissure in ano. 38.2% of patients with lower
gastrointestinal complaints and 3.6% of the total number of patients
presenting to the surgical OPD were attributed to fissure in ano.
A total of 1835 male patients presented to the surgical OPD during the
study period, of which 189 had lower gastrointestinal complaints.
Diagnosis of male patients presenting with lower
gastrointestinal complaints
42%
9%
18%
6%
2%
23%
Constipation
Hemorrhoids
Malignancy
Fistula
Abscess
Fissure in ano
CHART 2: Diagnosis of female patients presenting with
lower gastrointestinal complaints
9%
32%
1%
2%
TABLE 3: Diagnosis of female patients presenting with lower
gastrointestinal complaints
23%
Constipation 42
Hemorrhoids 29
Malignancy 2
Fistula 1
Abscess 12
Fissure in ano 41
TOTAL 127
33%
Constipation
Hemorrhoids
Malignancy
Fistula
Abscess
Fissure in ano
GASTROENTEROLOGY TODAY - AUTUMN 2019
9

FEATURE
TABLE 4: Age distribution of female patients diagnosed with
fissure in ano
60 years 1
TOTAL 41
A total of 50 patients with fissure in ano were admitted for surgical
procedures and their thyroid assay was subsequently done. 16
patients had hypothyroidism characterized by increased free TSH
values and low free T3 and free T4 according to the reference
range. The incidence of hypothyroidism in patients with fissure in
ano is 32%.
Discussion
Conclusion
Lower gastrointestinal symptoms form a significant proportion of people
attending the surgical outpatient department out of which one third are
diagnosed with fissure in ano.
The patients present with various types and degrees of symptoms and
complications all of which are distressing.
This positive association can be used to encourage screening of
patients diagnosed with fissure in ano for thyroid derangements. Also
patients diagnosed with hypothyroidism can be advised to manage their
constipation to prevent anal fissures.
Conflict of Interest: None
References
1. McCallion K, Gardiner KR. Progress in the understanding and
treatment of chronic anal fissure. Postgraduate medical journal.
2001 Dec 1;77(914):753-8.
Fissures were more common in the age group of 20 to 40
years with an incidence of 67.5% in males and 82.9% of
females attending the surgical outpatient department with lower
gastrointestinal complaints.
According to a study done by Unnikrishnan et al in eight cities
in India, the overall prevalence of hypothyroidism was 10.95%.
A significantly higher proportion of females with 15.86% as
compared to males with 5.02% were diagnosed. [6] In the present
study, the incidence of hypothyroidism is significantly higher.
In a population-based study done in Cochin on 971 adult
subjects, the prevalence of hypothyroidism was 3.9%. The
prevalence of subclinical hypothyroidism was high in this study
as well with 9.4%. In women, the prevalence was higher(11.4%),
when compared with men (6.2%). [7] Our study has an incidence
of 32% which is higher.
2. Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of
the inferior rectal artery: a possible cause of chronic, primary anal
fissure. Diseases of the Colon & Rectum. 1989 Jan 1;32(1):43-52.
3. Prohm P, Bönner C. Is manometry essential for surgery of
chronic fissure-in-ano?. Diseases of the colon & rectum. 1995 Jul
1;38(7):735-8.
4. Minguez M, Tomas-Ridocci M, Garcia A, Benages A. Pressure of the
anal canal in patients with hemorrhoids or with anal fissure. Effect
of the topical application of an anesthetic gel. Revista espanola de
enfermedades digestivas: organo oficial de la Sociedad Espanola
de Patologia Digestiva. 1992 Feb;81(2):103-7.
5. Yaylali O, Kirac S, Yilmaz M, Akin F, Yuksel D, Demirkan N,
Akdag B. Does hypothyroidism affect gastrointestinal motility?.
Gastroenterology research and practice. 2009;2009.
GASTROENTEROLOGY TODAY - AUTUMN 2019
The prevalence of hypothyroidism in India is 11%, 2% in the
UK and 4·6% in the USA. Coastal cities like Mumbai, Goa, and
Chennai, have a higher prevalence (11·7%) than cities located
inland (9·5%). [8] The present study has a higher incidence of
hypothyroidism.
In a study done by Velayutham et al, 11% of young females in
the south Indian population had elevated TSH levels. [9] In the
present study, the incidence is 32%.
Since the incidence of hypothyroidism in our study is higher than
the prevalence of hypothyroidism in the general population as
documented by multiple studies in the past, we can conclude that
there is a significant association between hypothyroidism and
development of fissure in ano.
6. Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari
N. Prevalence of hypothyroidism in adults: An epidemiological
study in eight cities of India. Indian journal of endocrinology and
metabolism. 2013 Jul;17(4):647.
7. Unnikrishnan AG, Menon UV. Thyroid disorders in India: An
epidemiological perspective. Indian journal of endocrinology and
metabolism. 2011 Jul;15(Suppl2):S78.
8. Bagcchi, Sanjeet. “Hypothyroidism in India: more to be done.” The
Lancet Diabetes & Endocrinology 2.10 (2014): 778.
9. Velayutham K, Selvan SS, Unnikrishnan AG. Prevalence of
thyroid dysfunction among young females in a South Indian
population. Indian journal of endocrinology and metabolism. 2015
Nov;19(6):781.
10

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11

POSTERS
Endoscope reprocessing:
we’re only human
We’re only human was an American movie directed by James Flood and
released in 1935. Even then, there was great interest in shifting from human
work to automated assembly lines. But what does this have to do with the
reprocessing of flexible endoscopes? In my opinion, it is related to today’s
reprocessing problems of these complex medical devices. For decades we
have known that flexible endoscopes – even when cleaned and disinfected -
can be a source of debris, biofilm and thus micro-organisms, leading to serious
infection problems. Just take a look at the headlines about contaminated,
so called ‘superbug’, endoscopes. However, manual reprocessing is still
underestimated and reprocessing staff are only human.
GASTROENTEROLOGY TODAY - AUTUMN 2019
12
The importance of endoscopy
Since the introduction of the first flexible endoscope in
1956 by Basil Hirschowitz and Larry Curtis, the number of
procedures using these devices has increased enormously.
Only in the United States approximately 75 million procedures
were performed in 2017 [idataresearch.com, 28 may 2018].
And it is expected that this number will increase in the next
decades. A procedure with a flexible endoscope has many
advantages compared to traditional procedures and they are
very safe. Of course, like any other procedure, there are also
potential complications like perforation, bleeding, pancreatitis
(as a result of ERCP) or infection. Focusing on the last one,
these infections can originate from the patients own bacterial
flora, or from exogenous flora, transmitted by a previously
used endoscope.
Complex, reusable devices
Flexible endoscopes are complex, reusable medical devices.
During a procedure they can become highly contaminated
with organic materials and bacteria. Studies have showed a
high bacterial contamination inside the channels of sometimes
more than 10^9 CFU per channel (one billion colony forming
units) [Rutala WA, Weber DJ. Reprocessing endoscopes:
United States perspective. J Hosp Infect. Apr 2004;56 Suppl
2: S27-31. Kaczmarek RG et al. Am J Med 1992;92:257-261].
Flexible endoscopes need to be thoroughly reprocessed
between each patient, to guarantee a safe subsequent use.
Simultaneously with the technical development, extensive use
of endoscopes and identified outbreaks due to contaminated
endoscopes, techniques for cleaning and disinfection were
improved. One of the most important innovations in endoscopy
was the introduction of high-level disinfection of endoscopes
[Sivak MV. Gastrointestinal endoscopy: past and future.
GUT. 2006, Aug; 55(8), 1061-1064).
The role of automated endoscope-disinfectors
With the introduction and increased usage of automated
high-level endoscope-disinfectors, practitioners developed
an utopic belief that the problem of contaminated endoscopes
would belong to the past. Now that the reprocessing process
was automated, controlled, and could be retrieved and
validated. Practitioners thought that manual cleaning was not
necessary anymore with these endoscope-disinfectors - which
also contained a cleaning and increased rinsing stage, with
reduced human failures in reprocessing. However, reality was
different: even with the use of these disinfectors, outbreaks
due to contaminated endoscopes kept occurring. Endoscopes
were still not clean enough after reprocessing [Kovaleva, 2013].
This is not a surprise.
Underestimated manual cleaning
With only flushing water with detergent to disinfectant through
the channels, automated endoscope-disinfectors were not
able to remove any debris, biofilm and thus micro-organisms.
Although some endoscope-disinfectors claim a 90% reduction
of debris in the first step inside cleaning [Alfa et al, 2006], the
manual cleaning before automated cleaning and disinfection is
still the most important step [Beilenhoff, ESGE-ESGENA 2018].
Manual brushing and flushing of the endoscope, using the
right procedures and techniques, removes > 90% of all debris,
biofilm and micro-organisms [Chu NS, McAlister D, Antonoplos
PA. 1998. Natural bioburden levels detected on flexible
gastrointestinal endoscopes after clinical use and manual
cleaning. Gastrointest. Endosc. 48:137–142]. The last 10%
can be removed by the automated endoscope-disinfector.
However, in daily practice, the manual cleaning stage is
downgraded to just a simple flush and brush, despite all
reported outbreaks and the detailed IFUs for manual cleaning.
The question is: why?
Time pressure in reprocessing units
Since the number of endoscopic procedures is increasing
enormously, there is a great pressure on the availability
of reprocessed endoscopes. With the high turnover of
endoscopes, time has become the key factor in many
endoscopy wards and reprocessing units. After use,

POSTERS
endoscopes should be available as fast as possible. There is
a continuous pressure to reduce reprocessing times. Every
minute counts. Also in the manual cleaning stage, and even
in the drying stage. Ofstead et al showed that in 45% of
cases key steps in reprocessing are skipped. In less than 50%,
manual cleaning and drying - the two most critical steps - are
performed according to instructions [Ofstead et al. Endoscope
reprocessing methods. A prospective study of human factors
and automation. Gastrointestinal Nursing. 2010; Vol 33. No 4,
pp 304-311]. In reality, only a few minutes are invested in
flushing, brushing, inspection and the leak test, without
following all steps of the reprocessing manual.
Also, it is known that when working under high pressure
mistakes can increase. Of course, we are only human.
75% of the reprocessing staff reported on a time pressure
and non-compliance with guidelines related to reprocessing
as a result [Beilenhoff U et al. Reprocessing in GI Endoscopy:
ESGE-ESGENA Position Statement. Endoscopy 2018; 50].
For decades we have known that time pressure sometimes
leads to reported outbreaks of infection. But what has been
done to reduce the risk? Okay, there were some critical reports,
guidelines were improved and recently an automated, video
controlled, cleaning unit (UltraZonic ® ) was introduced to
increase effectiveness and standardization. Hereby eliminating
human failures as a nice side effect. However, the required
reprocessing is still a point of discussion – especially
amongst managers.
Fingers pointed in the wrong direction
We are all pointing at the manufacturers. They have developed
complex, difficult to clean endoscopes and their reprocessing
manuals are hard to understand and on average more than a
hundred pages long, including over 150 steps. In my opinion
we are turning the world upside down. Of course, flexible
endoscopes are complex devices, and design flaws can lead
to problems, even of infectious origin. However, outbreaks
related to flexible endoscopes are only in 8% related to the
design of flexible endoscopes [Kovaleva, 2012]. It is possible
to clean, disinfect and dry endoscopes adequately following
the manufacturer’s instructions for use (IFUs) at all times.
[Muscarella et al. World J Gastrointestinal Endosc. 2014.
October 16; 6(10): 457-474 ISSN 1948-5190]. But we need
to be willing to invest time, dedicated and qualified personal,
and the right equipment and resources.
Training the human capital
We need to invest in training our personnel continuously.
It is well known that intensified training of endoscopists
(physicians) and nurse endoscopists is a successful way to
improve diagnosis and treatment, which might result in better
patient outcome [UEG, June 2014]. A recent survey shows a
positive effect in training reprocessing staff and regular audits
to ensure compliance to reprocessing guidelines [Beilenhoff U
et al. Reprocessing in GI Endoscopy: ESGE-ESGENA Position
Statement. Endoscopy 2018; 50].
But it is easier said than done: it is remarkable and even
perplexing that we still do not invest enough in continuous
training of the people reprocessing those complex instruments
on a daily basis. Not only to eliminate human failures, but to
improve quality and safety in endoscope reprocessing as well.
Resulting in less risks of exogenous infections due to an
improperly cleaned and disinfected endoscope.
Shift from quantity to quality
I call upon the field, to shift from reprocessing quantity to
quality. Despite all innovations, such as disposable ERCP
tips (Pentax), new drying and storage systems like the
PlasmaTYPHOON, or even upcoming disposable endoscopes,
the human factor will always stay important. Quoting Alibabafounder
Jack Ma ‘Computers have only chips. Humans have
a heart. And it’s the heart in which wisdom is originated’.
It is never too late to invest in human capital, especially when
reprocessing complex medical devices like flexible endoscopes.
Paul J Caesar
(Tjongerschans Hospital, Heerenveen,
the Netherlands) Expert in infection control,
sterile medical devices and reprocessing
flexible endoscopes
GASTROENTEROLOGY TODAY - AUTUMN 2019
13

NEWS
You’ve probably
never seen an oral iron
like FERACCRU ® before
For the treatment of adults with iron deficiency (ID) 1
GASTROENTEROLOGY TODAY - AUTUMN 2019
14
PRESCRIBING INFORMATION: Feraccru 30mg hard
capsules (ferric maltol)
Please refer to the full Summary of Product Characteristics
(SmPC) before prescribing.
Presentation: Red hard capsules. Each capsule contains
30 mg iron (as ferric maltol). Indication: Feraccru is
indicated in adults for the treatment of iron deficiency.
Dosage and Administration: Adults: Feraccru should be
taken orally. The whole capsule should be taken on an
empty stomach (with half a glass of water). The
recommended dose is one capsule twice daily, in the
morning and evening. The absorption of iron is reduced
when Feraccru is taken with food. Treatment duration will
depend on the severity of iron deficiency but generally at
least 12 weeks treatment is required. The treatment should
be continued as long as necessary to replenish the body
iron stores according to blood tests. Elderly: No dose
adjustment is necessary. Children: The safety and efficacy
of Feraccru in children (17 years and under) has not yet
been established. No data are available. Patients with
hepatic or renal impairment: No clinical data is available
in this patient population. Contraindications:
Hypersensitivity to the active substance or to any of the
excipients; Haemochromatosis and other iron overload
syndromes; Patients receiving repeated blood
transfusions. Warnings and precautions: Feraccru should
not be used in patients with inflammatory bowel disease
(IBD) flare or in IBD patients with haemoglobin (Hb) levels

NEWS
‘
The taboo subject of
constipation: undermining
patient’s quality of life and
putting a preventable strain
on NHS
The Bowel Interest Group launches 2019
‘Cost of Constipation’ report
26th July 2019 - Independent
multidisciplinary organisation The Bowel
Interest Group has released its ‘Cost of
Constipation’ report revealing the impact
that the taboo subject of constipation has on
the UK. This latest report not only explores
the significant cost of constipation to the
NHS but highlights the damaging impact on
patient lives.
The report shows that poor bowel health and
chronic constipation, which are debilitating
for hundreds and thousands of people in
the UK, cost the NHS a preventable £71
million in unplanned hospital admissions for
constipation in 2017/18. This cost is likely to
be much higher when GP visits, home visits
and over the counter laxatives are taken into
account. Specifically, the report shows that:
• In 2017/18, 71,430 people with
constipation were admitted to hospital in
England. This is equivalent to 196 per day.
• Close to three quarters of these were
unplanned emergency admissions,
equivalent to 144 per day.
• £91 million was spent on prescription
laxatives in 2017/18.
• The cost of treating constipation in
2017/18 is equivalent to funding 7043
newly-qualified nurses for a year.
• On average, 6.3 people visit a GP about
constipation each week.
The Cost of Constipation report also lays
bare the embarrassment and distress
caused by the condition, revealing that
one in five people are embarrassed to talk
about constipation with their GP, and some
people find themselves unable to leave the
house for social activities. In addition to the
physical problems constipation can cause
such as haemorrhoids, chronic pain and
urinary tract infections, the report highlights
the high incidence of anxiety disorders and
depression in people with constipation.
Dr Benjamin Disney, Consultant
Gastroenterologist, University Hospitals
Coventry and Warwickshire NHS Trust,
comments: “Many people see constipation
as a simple, straightforward, easily treated
condition that does not greatly affect people.
However, from the Cost of Constipation
report and my clinical experience, this is
often not the case, with the condition being
under-reported and often poorly managed,
leading to a significant cost to the NHS and
having a negative impact on patients’ overall
health and quality of life. The Bowel Interest
Group aims to tackle and raise awareness of
the important issue of constipation.”
Patients, clinicians and other interested
parties may download the full report
free of charge by visiting: https://
bowelinterestgroup.co.uk/cost-ofconstipation-report-2019-public.
The Complete FIT Solution
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Alpha Laboratories has partnered with many of the FIT pioneers to
further expand the knowledge of the use of FIT for symptomatic
patients. For example, THE NICE FIT STUDY (www.nicefitstudy.com)
has now generated over 11,500 data sets, doubling the data reviewed
by NICE across 10 studies. With many new publications in print, or
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GASTROENTEROLOGY TODAY - AUTUMN 2019
The FIT Solution_Oct_19.indd 1 19/09/2019 12:04:56
15

NEWS
Northern Ireland patients
first to use exercise in
overcoming treatment for
deadliest common cancer
Northern Ireland pancreatic cancer
patients will be the first in the UK to trial
an innovative new exercise programme to
aid their recovery from the traumatic 12-
hour operation needed to save their lives,
after researchers from Queen’s University
Belfast were awarded a grant of more than
£100,000 from Pancreatic Cancer UK.
The grant from Pancreatic Cancer UK’s
Research Innovation Fund is the charity’s first
ever investment in a research project based
in Northern Ireland. The charity believes that,
if it is successful, the project has significant
potential to improve the quality of life for
patients who have surgery, an area of research
that has previously been under-developed
because of the urgent need to find new
treatments and improve diagnosis. Pancreatic
cancer has the lowest survival of all common
cancers, with less than seven per cent of
people with the disease in Northern Ireland
living for five years.
Surgery is the only cure for pancreatic cancer
but it can have a traumatic impact on patients.
The procedure involves removing all or part of
the pancreas and making major changes to
the digestive system, meaning patients can
experience serious side effects - including
pain, fatigue and anxiety - in addition to the
effects of chemotherapy. The burden of these
symptoms can damage a patient’s recovery as
well their long-term health and wellbeing.
Researchers will work extensively with local
pancreatic cancer patients who have had
surgery to design bespoke exercise programs
tailored toward managing each individual’s
symptoms. Exercise has previously been
shown to benefit patients with other cancers
such as breast and prostate, but the two-year
study by Queen’s University will be the first
time it has been trialled with those treated for
pancreatic cancer. Patients will be supported
in undertaking resistance and aerobic exercise
at their own pace, alongside post-operative
chemotherapy. It is hoped that a successful
trial in Belfast will see the project expand to
other sites in the UK benefiting more patients.
Dromore, County Down resident Tom
Hawthorne knows all about the impact of the
operation. He was diagnosed with pancreatic
cancer in August 2017 and quickly scheduled
for surgery. He credits cycling with helping
him to overcome the side effects. Tom, 61,
said: “I was told that it was going to be a pretty
tough operation but at that stage I did not fully
grasp what that actually meant. For me, the
operation was totally devastating - it was really
tough, physically and psychologically.
“From my first day out of intensive care I
was determined to give it my best shot after
speaking to my surgeon. From blowing that
little pipe to keep the ball up, to family helping
me around the corridors and friends helping
me to the park, it all helped me so much. Then
eventually getting back on my bike. All this for
me made me so much stronger in every way
and had a massive impact on my recovery.
Not everyone can do it but it’s well worth doing
your best. You will feel the benefit.”
Dr Chris MacDonald, Head of Research
at Pancreatic Cancer UK, said: “Research
into pancreatic cancer has been grossly
underfunded for decades, stifling innovation
and delaying the breakthroughs we so badly
need to see. The potential positive impact of
this project devised by the team at Queen’s
University Belfast is hugely exciting and I am
delighted it is our first-ever funded research in
Northern Ireland.
“While it can be lifesaving, the combination
of such extensive surgery followed by
chemotherapy can take a heavy toll. It may
sound counterintuitive, but exercise could
be key to mitigating many of the symptoms
that affect a patient’s quality of life. We are
determined to explore innovative ideas such
as this one to ensure patients can make the
fullest possible recovery.”
The research at Queen’s University Belfast is
one of six promising new projects to receive a
grant from Pancreatic Cancer UK’s Research
Innovation Fund in 2019. Grants are intended
to help combat the cycle of underfunding which
has hampered desperately needed progress on
diagnosis, treatment and survival for pancreatic
cancer. By funding cutting-edge projects,
Pancreatic Cancer UK helps researchers take
their work to the next stage of development and
closer to much-needed breakthroughs. Since
its creation Pancreatic Cancer UK’s Research
Innovation Fund has awarded more £2 million to
research projects, which have gone on to attract
more than £14 million of additional funding.
GASTROENTEROLOGY TODAY - AUTUMN 2019
Dr Gillian Prue, Lead Researcher from the
School of Nursing and Midwifery at Queen’s
University Belfast, said: This is a fantastic
opportunity for people with pancreatic cancer
in NI and we are very grateful to Pancreatic
Cancer UK for their support. We hope that by
undertaking a supervised exercise programme
during chemotherapy patients may avoid
an almost inevitable decline in function.
Increasing activity levels may help patients
tolerate chemotherapy treatment and reduce
treatment side effects. This is the first time
a study such as this has been undertaken
in the UK, so we will be working very closely
with our patients to ensure the programme is
achievable and meets their needs.”
16

The only licensed treatment for the
reduction in recurrence of overt
hepatic encephalopathy (OHE) 1
NEWS
At home they
are still at risk;
…TARGAXAN ®
rifaximin-α
reduces the risk
of recurrence
of overt hepatic
encephalopathy. 2
Long-term secondary prophylaxis in hepatic
encephalopathy (HE) 3
UK&IE Prescribing Information: Targaxan 550mg (rifaximin-α)
REFER TO FULL SUMMARY OF PRODUCT CHARACTERISTICS (SmPC)
BEFORE PRESCRIBING
Presentation: Film-coated tablet containing rifaximin 550 mg.
Uses: Targaxan is indicated for the reduction in recurrence of episodes
of overt hepatic encephalopathy in patients ≥ 18 years of age.
Dosage and administration: Adults 18 years of age and over: 550 mg
twice daily, with a glass of water, with or without food for up to 6 months.
Treatment beyond 6 months should be based on risk benefit balance
including those associated with the progression of the patients hepatic
dysfunction. No dosage changes are necessary in the elderly or those
with hepatic insufficiency. Use with caution in patients with renal
impairment.
Contraindications: Contraindicated in hypersensitivity to rifaximin,
rifamycin-derivatives or to any of the excipients and in cases of
intestinal obstruction.
Warnings and precautions for use: The potential association of
rifaximin treatment with Clostridium difficile associated diarrhoea and
pseudomembranous colitis cannot be ruled out. The administration
of rifaximin with other rifamycins is not recommended. Rifaximin
may cause a reddish discolouration of the urine. Use with caution
in patients with severe (Child-Pugh C) hepatic impairment and in
patients with MELD (Model for End-Stage Liver Disease) score > 25.
In hepatic impaired patients, rifaximin may decrease the exposure of
concomitantly administered CYP3A4 substrates (e.g. warfarin,
antiepileptics, antiarrhythmics, oral contraceptives). Both decreases and
increases in international normalized ratio (in some cases with bleeding
events) have been reported in patients maintained on warfarin and
prescribed rifaximin. If co-administration is necessary, the international
normalized ratio should be carefully monitored with the addition or
withdrawal of treatment with rifaximin. Adjustments in the dose of
oral anticoagulants may be necessary to maintain the desired level of
anticoagulation. Ciclosporin may increase the rifaximin Cmax
Pregnancy and lactation: Rifaximin is not recommended during
pregnancy. The benefits of rifaximin treatment should be assessed
against the need to continue breastfeeding.
Side effects: Common effects reported in clinical trials are dizziness,
headache, depression, dyspnoea, upper abdominal pain, abdominal
distension, diarrhoea, nausea, vomiting, ascites, rashes, pruritus, muscle
spasms, arthralgia and peripheral oedema. Other effects that have
been reported include: Clostridial infections, urinary tract infections,
candidiasis, pneumonia cellulitis, upper respiratory tract infection and
rhinitis. Blood disorders (e.g. anaemia, thrombocytopenia). Anaphylactic
reactions, angioedemas, hypersensitivity. Anorexia, hyperkalaemia and
dehydration. Confusion, sleep disorders, balance disorders, convulsions,
hypoesthesia, memory impairment and attention disorders.
Hypotension, hypertension and fainting. Hot flushes. Breathing difficulty,
pleural effusion, COPD. Gastrointestinal disorders and skin reactions.
Liver function test abnormalities. Dysuria, pollakiuria and proteinuria.
Oedema. Pyrexia. INR abnormalities. Prescribers should consult the
SmPC in relation to all adverse reactions.
UNITED KINGDOM
Legal category: POM
Cost: Basic NHS price £259.23 for 56 tablets
Marketing Authorisation holder: Norgine Pharmaceuticals Limited,
Norgine House, Widewater Place, Moorhall Road, Harefield, Uxbridge,
UB9 6NS, UK
Marketing Authorisation number: PL 20011/0020
IRELAND
Legal category: Prescription only
Cost: €262.41 for 56 tablets
Marketing Authorisation holder: Norgine B.V. Hogehilweg 7, 1101 CA
Amsterdam ZO, Netherlands
Marketing Authorisation number: PA 1336/009/001
For further information contact:
Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road,
Harefield, Middlesex UB9 6NS
Telephone: 01895 826 606
E-mail: Medinfo@norgine.com
Ref: UK/XIF5/0119/0477
Date of preparation: January 2019
United Kingdom
Adverse events should be reported. Reporting forms and
information can be found at www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to Medical
Information at Norgine Pharmaceuticals Ltd on:
Tel. +44 (0)1895 826 606
Email Medinfo@norgine.com
Ireland
Healthcare professionals are asked to report any
suspected adverse reactions via HPRA Pharmacovigilance,
Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971;
Fax: +353 1 6762517. Website: www.hpra.ie;
E-mail: medsafety@hpra.ie. Adverse events should
also be reported to Medical Information at
Norgine Pharmaceuticals Ltd on: Tel. +44 (0)1895 826 606
Email Medinfo@norgine.com
References:
1. National Institute for Health and Care Excellence.
Rifaximin for preventing episodes of overt hepatic encephalopathy:
appraisal guidance TA337 for rifaximin.
Available from: http://www.nice.org.uk/guidance/ta337
2. TARGAXAN ® 550 Summary of Product Characteristics.
Available for the UK from: https://www.medicines.org.uk/emc
Available for Ireland from: www.medicines.ie
3. Mullen KD, et al. Clin Gastroenterol Hepatol
2014;12(8):1390-97.
Product under licence from Alfasigma S.p.A. TARGAXAN is a
registered trademark of the Alfasigma group of companies, licensed
to the Norgine group of companies. NORGINE and the sail logo are
registered trademarks of the Norgine group of companies.
UK/XIF5/0219/0487
Date of preparation: February 2019.
GASTROENTEROLOGY TODAY - AUTUMN 2019
17

NEWS
Rising stars of
Gastroenterology &
Hepatology honoured at the
2019 Dr Falk Pharma/Guts
UK Awards
An investigation into why and how normal
colon cells mutate into cancer, how best to
reduce the harm caused by blood borne liver
viruses in prisons and the potential benefits of
faecal microbial transplantation (FMT) in the
treatment of chronic liver disease. These are
just a few of the highly significant research and
clinical projects explored by the ten worthy
winners of the 2019 Dr Falk Pharma UK/Guts
UK Charity Awards. The winners, who included
medical students, junior doctors, nurses and
dietitians were presented with their awards
during a dinner on Tuesday June 18th at the
British Society of Gastroenterology (BSG)
Annual Meeting in Glasgow.
Now in their 13th year, the Dr Falk Pharma UK/
Guts UK Charity Awards have become widely
recognised within the gastroenterology and
hepatology community for the support and
endorsement they offer junior doctors starting
out on their careers. Through nurse and
dietitian prizes, the awards also acknowledge
and reward the innovation and dedication that
these HCPs bring to their patients.
Professor Chris Hawkey, President of Guts UK
Charity, who co-presented the ceremony says:
‘These awards have supported numerous
medical students, junior doctors, nurses
and dietitians at crucial early stages in their
careers. These are the most talented health
professionals and leaders of tomorrow and
support at this early stage helps to signal their
potential to them and their peers and foster
self-belief as the bright stars of tomorrow. The
awards continue to be highly competitive and
help to attract the brightest and the best to the
field of UK gastroenterology.
‘Guts UK is delighted to continue its collaboration
with Dr Falk Pharma UK, and the Trustees of
Guts UK greatly value Dr Falk’s clear vision and
ongoing support of this valuable initiative.’
Ms Jaclyn Tan was awarded the Medical Student
Prize for her project focussing on the diagnosis
and management of patients with spontaneous
bacterial peritonitis (SBP), a frequent and severe
complication with a high mortality rate in patients
with cirrhosis and ascites.
‘It is a great honour to be awarded the Dr
Falk/Guts UK Medical Student Prize,’ said Ms
Tan, who will return to take up her 4th year of
medicine at the University College Medical
School in September.
‘This has fuelled my drive to undertake
further work within the discipline, as I strive
to contribute to the scientific community and
apply research findings in the clinical setting to
improve patient care’
Advanced Dietitian in Paediatric
Gastroenterology, Ms Isobel Connolly won
the Dietitian Award for her work establishing
a dietetic-led clinic for paediatric patients
with Coeliac Disease. Her Manager, Principle
Paediatric Dietician Nicole Dos Santos explained:
‘This service has improved patient care
significantly by increasing patient access
to follow up and decreasing the number of
appointments patients require, improving
patient attendance and streamlining dietetic
review with blood monitoring.’
Dr Riadh Jazrawi, Medical Director of Dr Falk
Pharma UK and co-presenter of the Awards
commented:
‘This year, as always, we take huge pleasure
in being able to reward and support the talent,
work ethic and passion displayed by these
young medical students and doctors.
‘We sincerely hope that, in doing so, we can
support and encourage them into become
the next generation of hepatologists and
gastroenterologists.
‘We are also delighted to honour the
commitment displayed by our nurse and
dietitian award winners, who often in their own
time, instigate innovative projects that lead to
great benefits for patients.’
GASTROENTEROLOGY TODAY - AUTUMN 2019
18

NEWS
GASTROENTEROLOGY TODAY - AUTUMN 2019
19

NEWS
ARE YOU DOING YOUR BEST
FOR PBC PATIENTS?
Inadequate or intolerant response to UDCA is defined as
ALP >1.67 x ULN (>200 IU/L) and/or bilirubin 2 x ULN 1
PBC expertise is closer
than you think...
Consider referral to 1 of 26
PBC hubs in England or a Liver
Centre comprised of specialist
multidisciplinary teams for
individualised patient treatment
and second-line therapy.
6
3 4
2
1
26
11
32
15
9
7
24
23
16
12
13
25
21 8
14
Find your nearest PBC referral
hub at www.uk-pbc.com/
newtherapiesinpbc/
Find your nearest Liver Centre
at www.britishlivertrust.org.uk/
liver-information/useful-links/
liver-and-transplant-units/
Liver Centres
PBC Hubs
30
33 31
5
20
28
17
29
18
27 19
22
10
1. Aberdeen Royal Infirmary
2. Ninewells Hospital, Dundee
3. Glasgow Royal Infirmary
4. Edinburgh Royal Infirmary
5. University Hospital Wales,
Cardiff
6. Royal Victoria Hospital,
Belfast
7. Aintree Univ Hosp NHS FT
8. Barts Health NHS Trust
9. Bradford Teaching
10. Cambridge Univ Hosp
NHS FT
11. East Lancashire Hosps
NHS Trust
12. Hull & East Yorkshire
NHS Trust
13. King’s College Hosp
NHS FT
14. Imperial College
Healthcare Trust
15. Leeds Teaching Hosp
NHS Trust
16. Manchester University
NHS FT
17. Nottingham Univ Hosp
NHS Trust
18. Oxford Univ Hosps NHS FT
19. Portsmouth Hosps
NHS Trust
20. Royal Devon & Exeter FT
21. Royal Free London NHS FT
22. Royal Surrey County Hosp
NHS FT
23. Royal L’pool/Broadgreen
Univ Trust
24. Sheffield Teaching
Hosp FT
25. St George’s Univ Hosps
NHS FT
26. The Newcastle upon Tyne
Hosps FT
27. Univ Hosp Southampton
NHS FT
28. Univ Hosps Birmingham
NHS FT
29. Univ Hosps Leicester
NHS Trust
30. Univ Hosps Plymouth
NHS Trust
31. University Hosp Bristol
NHS FT
32. York Teaching Hospital
NHS FT
33. Royal Gwent Hospital,
Newport
Find out more information in the BSG guidelines at www.bsg.org.uk/clinical/bsg-guidelines.html
GASTROENTEROLOGY TODAY - AUTUMN 2019
Abbreviated Prescribing Information
OCALIVA ® (obeticholic acid)
(Please refer to the Full Summary of Product Characteristics (SmPC) before prescribing)
Presentation: OCALIVA supplied as film-coated tablets containing
5 mg and 10 mg obeticholic acid. Indication: For the treatment of
primary biliary cholangitis (also known as primary biliary cirrhosis)
in combination with ursodeoxycholic acid (UDCA) in adults with
an inadequate response to UDCA or as monotherapy in adults
unable to tolerate UDCA. Dosage and administration: Oral
administration. Hepatic status must be known before initiating
treatment. In patients with normal or mildly impaired (Child Pugh
Class A) hepatic function, the starting dose is 5 mg once daily.
Based on an assessment of tolerability after 6 months, the dose
should be increased to 10 mg once daily if adequate reduction of
alkaline phosphatase (ALP) and/or total bilirubin have not been
achieved. No dose adjustment of concomitant UDCA is required
in patients receiving obeticholic acid. For cases of severe pruritus,
dose management includes reduction, temporal interruption or
discontinuation for persistent intolerable pruritus; use of bile acid
binding agents or antihistamines (see SmPC). Moderate to Severe
Hepatic Impairment: In patients with Child-Pugh B or C hepatic
impairment, a reduced starting dose of 5mg once weekly is required.
After 3 months, depending on response and tolerability, the starting
dose may be titrated to 5 mg twice weekly and subsequently to
10 mg twice weekly (at least 3 days between doses) if adequate
reductions in ALP and/or total bilirubin have not been achieved.
No dose adjustment required in Child Pugh Class A function. Mild
or moderate renal impairment: No dose adjustments are required.
Paediatric population: No data. Elderly: No dose adjustment
required; limited data exists. Contraindications: Hypersensitivity to
the active substance or any excipients. Complete biliary obstruction.
Special warnings and precautions for use: After initiation, patients
should be monitored for progression of PBC with frequent clinical
and laboratory assessment of those at increased risk of hepatic
decompensation. Dose frequency should be reduced in patients
who progress from Child Pugh A to Child Pugh B or C Class disease.
Serious liver injury and death have been reported in patients with
moderate/severe impairment who did not receive appropriate dose
reduction. Liver-related adverse events have been observed within
the first month of treatment and have included elevations in alanine
amino transferase (ALT), aspartate aminotransferase (AST) and
hepatic decompensation. Interactions: Following co-administration
of warfarin and obeticholic acid, International Normalised Ratio
(INR) should be monitored and the dose of warfarin adjusted, if
needed, to maintain the target INR range. Therapeutic monitoring of
CYP1A2 substrates with narrow therapeutic index (e.g. theophylline
and tizanidine) is recommended. Obeticholic acid should be taken
at least 4-6 hours before or after taking a bile acid binding resin,
or at as great an interval as possible. Fertility, pregnancy and
lactation: Avoid use in pregnancy. Either discontinue breastfeeding
or discontinue/abstain from obeticholic acid therapy
taking into account the benefit of breast-feeding for the child
and the benefit of therapy for the woman. No clinical data on
fertility effects. Undesirable effects: Very common (≥1/10) adverse
reactions were pruritus, fatigue, and abdominal pain and discomfort.
The most common adverse reaction leading to discontinuation was
pruritus. The majority of pruritus occurred within the first month of
treatment and tended to resolve over time with continued dosing.
Other commonly (≥ 1/100 to < 1/10) reported adverse reactions are,
thyroid function abnormality, dizziness, palpitations, oropharyngeal
pain, constipation, eczema, rash, arthralgia, peripheral oedema,
and pyrexia. Please refer to the SmPC for a full list of undesirable
effects. Overdose: Liver-related adverse reactions were reported
with higher than recommended doses of obeticholic acid. Patients
should be carefully observed, and supportive care administered,
as appropriate. Legal category: POM Marketing authorisation
numbers: EU/1/16/1139/001 & 002 Marketing authorisation holder:
Intercept Pharma International Ltd, 31–36 Ormond Quay Upper,
Dublin 7, Ireland Package Quantities and Basic NHS cost: OCALIVA
5 mg and 10 mg £2,384.04 per bottle of 30 tablets. Date of revision:
10th June 2019
Adverse events should be reported. Reporting forms and
information can be found at www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to
Intercept Pharma Ltd on +44 (0)330 100 3694
or email: drugsafety@interceptpharma.com
20
ALP, alkaline phosphatase; PBC, primary biliary cholangitis; UDCA, ursodeoxycholic acid; ULN, upper limit of normal.
1. EASL guidelines. J Hepatol. 2017;67:145–172.
UK-PP-PB-0464 September 2019

NEWS
Okayama University
research: Early gastric
cancer endoscopic
diagnosis system using
artificial intelligence
(Okayama, 15 July) Researchers at
Okayama University have developed
an early gastric cancer endoscopic
diagnosis system using artificial
intelligence (AI). The details were
presented at the Congress of the Japan
Gastroenterological Endoscopy Society
(JGES), May 31 – June 2, 2019, Tokyo.
According to data released in 2017 by
Japan’s Ministry of Health, Labor, gastric
cancer ranks third in cancer deaths in
Japan: second in men and fourth in women.
Treatment of early-stage gastric cancer
includes endoscopic surgery (ESD),
which can save the stomach, and surgical
procedures that require gastrectomy.
However, although advances in endoscopic
treatment technology has led to the early
detection of gastric cancer, decisions on
whether to use endoscopy treatment or
surgery mainly depend on how deep the
cancer has invaded the stomach wall.
Furthermore, these decisions are made by
careful examination of endoscopic images
by experienced physicians. At present,
there are many cases where endoscopic
treatment is performed first where surgery
would have been more appropriate and vice
versa.
(Convolutional Neural Network) published
by Google on numerical analysis software
MATLAB.
Next, the researchers used the ResNet,
which is a 152-layer convolutional
neural network, to conduct intramucosal
endoscopic resection among patients
treated for early gastric cancer at Okayama
University Hospital.
Using endoscopic images of 100
cancers (M group) and 50 submucosal
invasion cancers (SM-ESD group) and 50
submucosal invasion cancers (SM-OPE
group) who had undergone surgery from
the beginning, the researchers built the AI
system and verified its diagnostic accuracy.
The diagnostic accuracy of intramucosal
cancer by artificial intelligence diagnostic
system was sensitivity 82.7%, specificity
63.0%, positive predictive value 69.1%,
negative predictive rate 78.4% in image
unit, and sensitivity 82.0% in case unit.
The specificity was 71.0%, the positive
predictive value was 73.9%, and the
negative predictive value was 79.8%.
In addition, the correct diagnosis rate for
deep-seated diagnosis of early gastric
cancer as a combination of intramucosal
cancer and submucosal invasion cancer
was 72.8% in image units and 76.5% in
case units.
Implications of the research
At present, gastroenterological endoscope
medical diagnosis and treatment is based
on experienced practicing physicians
examining images.
As a result, the diagnostic ability of
individual doctors varies, and with increases
in the number of medical services in the
future, there is concern about the possibility
of oversight of cancer and increases in
misdiagnosis. If automatic diagnosis of
digestive tract endoscope images by AI is
realized, then ‘automated diagnosis logic’
will be added to endoscope technology for
real time diagnosis.
Automatic diagnosis will be possible and
it will greatly improve the current status of
relying on the diagnostic ability of individual
endoscopy physicians.
With this background, Professor Yoshiro
Kawahara of the Graduate School of
Medical and Dental Sciences, Okayama
University, and colleagues have developed
artificial intelligence (AI)-based endoscope
for early detection of gastric cancer. These
research results were presented at the 97th
Congress of the Japan Gastroenterological
Endoscopy Society (JGES), May 31 – June
2, 2019, Tokyo.
First the prototype of the system to obtain
the depth of early gastric cancer was
constructed with GoogLeNet to match
purpose (metastatic learning) by using
the image recognition ability of CNN
GASTROENTEROLOGY TODAY - AUTUMN 2019
21

NEWS
GASTROENTEROLOGY TODAY - AUTUMN 2019
How intestinal bacteria can
cause depression
A research group from Graz is investigating
the complex interaction between the
intestine and the brain. In a project funded
by the Austrian Science Fund FWF, the team
has gained new insights into how intestinal
bacteria, the immune system and obesity
can lead to mental illnesses.
headed by the neuropharmacologist and
neurogastroenterologist Peter Holzer from
Graz was able to identify a number of concrete
factors that can trigger psychological changes
in mice in a recently completed basic-research
project funded by the Austrian Science Fund
It has been known for quite some time that published studies,” says principal investigator
the proverbial “gut feeling” has a real medical Peter Holzer. “In addition to the direct neural
basis. The intestine has its own nervous pathways between intestine and brain, which
system, also known as the “abdominal brain” we have known about for a long time, there are
owing to its size and complexity, and it is many intestinal hormones that carry messages
closely connected to the brain. Processes in to the brain, as well as a huge immune system
the intestine cause changes in the brain and, that releases messenger substances when
conversely, psychological factors influence stimulated. In recent years, the gut microbiota
the intestine. How far this interaction goes and has become an additional factor. This consists
how exactly it works, however, has not yet been of a huge number of monocellular organisms
fully understood. There are indications that the
that also release substances and are believed
intestine may be involved in the development
to play an important role in the body’s
of GastroToday_Jan_2019_v4 psychiatric diseases. A research 26/01/2019 group 09:39 information Page 1 system.” According to Holzer,
many people are
FWF.
Intestine affects the brain
“The connection between the intestinal nervous
system and the brain has been known for a
long time, but the situation has become more
complex if you consider the most recently
familiar with a
strong connection
between brain
and gut. “But we
are not usually
aware of such
an amount of
information
reaching the brain
from the gut. This
information is fed
into brain areas
that are important
for our mood and
emotions.”
Feeling ill
because of
bacteria in the
intestine
Holzer and
his team have
spent five years
investigating
various signalling
pathways
which intestinal
processes can
use to influence
the brain.
One objective
of the project was to clarify how certain
bacteria in the gut alert the immune system
and thus trigger a feeling of illness. “The
immune system learns early on to tolerate
the microorganisms in the gut. That starts
in infancy,” explains Holzer. “When some
substances produced by bacteria penetrate
the intestinal wall, this certainly creates an
immune reaction and, associated with it, a
sense of being ill.” Specifically, he investigated
the so-called “endotoxin lipopolysaccharide”
(LPS), which is released by certain intestinal
bacteria and stimulates the immune system,
giving us a sense of being ill.
“If you suffer an infection with bacteria you will
feel tired, have muscle pain, lose your appetite
and become withdrawn. This is a sensible
reaction of the body, helping it to cope quickly
with the infection,” says the researcher.
“There is evidence, however, that this reaction
could be triggered in humans by intestinal
bacteria, even when there is no infection at
all.” Holzer’s team were able to show that other
substances produced by bacteria, so-called
“peptidoglycans”, enhance the effect of LPS.
“We believe that lipopolysaccharide is only
one of several factors contributing to the
development of mental illness.”
High-fat diet as a risk factor for depression
Holzer sees this physical reaction of “feeling
ill” in the larger context of intestinal influences
on the human psyche, and in particular as a
possible trigger for psychiatric diseases. “We
know from psychiatry and nutritional science
that being overweight increases the risk of
depression and depressive mood disorders.
Moreover, it has also been known for about 15
years that there is a great difference between
the gut microbiota of healthy and severely
overweight people,” Holzer notes. One result
of the project provides concrete information
on how processes in the intestine can trigger
depressive behaviour.
The team subjected mice to a high-fat diet
and analysed their behaviour. In addition to
the chemical changes in the brain that are
associated with depression, they also detected
concomitant behavioural changes. According
to Holzer, it is difficult but not impossible to
detect this in mice. “Depressive people lose
their joy in certain things. This anhedonic, or
listless, behaviour was something we were
able to identify in the mice that were given a
high-fat diet.” Their method was to offer the
mice regular water and sugar water as an
22

NEWS
alternative. Whereas healthy mice prefer sugar
water, the mice in Holzer’s experimental setup
went for it much less often. In the next step,
their gut microbiota was severely depleted
by the administration of antibiotics to find out
whether intestinal microbes contributed to
depressive behaviour after a high-fat diet. The
results are due to be published soon.
Fat hormone as a trigger
Holzer’s team has also identified a possible
signalling pathway to explain how depressive
behaviour can be triggered by a high-fat diet.
The hormone “leptin”, which is released by
fat cells, seems to play a role here. Mice that
are unable to produce this hormone gain the
same amount of weight as other mice when
they eat high-fat foods, but tend not to show
the behaviour associated with depression.
“The role of leptin has not yet been clearly
settled in the literature. We were able to show
at least that leptin is important in this context.”
Holzer suspects that the release of leptin is
linked to short-chain fatty acids produced by
microorganisms in the intestine from fibre-rich
food. The microbiota of the intestine therefore
also seems to play an important role in the
context of depression induced by obesity.
Personal details
Peter Holzer is Professor of Experimental
Neurogastroenterology at the Medical
University of Graz and Head of the Research
Unit for Translational Neurogastroenterology.
For three decades his research has
focussed on the communication between the
gastrointestinal tract and the brain.
Publications
Hassan AM, Mancano G, Kashofer K, Fröhlich
EE, Matak A, Mayerhofer R, Reichmann F,
Olivares M, Neyrinck AM, Delzenne NM, Claus
SP, Holzer P.: High-fat diet induces depressionlike
behaviour in mice associated with changes
in microbiome, neuropeptide Y, and brain
metabolome, in: Nutritional Neuroscience 2018
Fröhlich EE, Farzi A, Mayerhofer R, Reichmann
F, Jacan A, Wagner B, Zinser E, Bordag N,
Magnes C, Fröhlich E, Kashofer K, Gorkiewicz
G, Holzer P.: Cognitive impairment by
antibiotic-induced gut dysbiosis: analysis of
gut microbiota-brain communication, in: Brain,
Behaviour and Immunity 56, 2016
Farzi A, Reichmann F, Meinitzer A, Mayerhofer
R, Jain P, Hassan AM, Fröhlich EE, Wagner
K, Painsipp E, Rinner B, Holzer P.: Synergistic
effects of NOD1 or NOD2 and TLR4 activation
on mouse sickness behavior in relation to
immune and brain activity markers, in: Brain,
Behaviour and Immunity 44, 2015
Inflammatory Bowel Disease
- first Annual Report on
the Use of Biologics in
IBD, published by the IBD
Registry
The IBD Registry, one of the largest clinical
registries in Europe for Inflammatory Bowel
Diseases, has launched its first Annual
Report on the Use of Biologic Therapies in
England & Wales.
The Registry, a not-for-profit company, is
responsible for running the National Audit
of Biological Therapies in IBD, targeted at a
group of diseases which affect around half a
million people in the UK.
The purpose of the report is to consolidate in
one place annual changes and trends across
a basket of key performance indicators used
in the Biological Therapies Audit in IBD and is
based on a dataset from 73 participating IBD
treatment centres in
England Wales.
The report includes
the cumulative results
up to January 2019
from April 2016 when
the Registry assumed
the role of supporting
the National Audit
of Biological
Therapies from the
Royal College of
Physicians.
It is expected the
year-on-year changes
will be primarily
of interest to IBD
clinicians but also
possibly to some
patients, industry,
healthcare managers
and others involved in
IBD services.
Dr Stuart Bloom,
Registry Medical
Director, said, “This
is our first annual
report on biologic therapies, and we hope
that it gives a sense of how clinical and data
management in IBD has been changing for
the better, both more widely and over many
years. For example, vital information used
by clinicians to treat patients is increasingly
captured for the Registry’s database at the
point of care rather than retrospectively, with
the associated benefits of greater accuracy of
information on a patient’s disease experience.
“The report also makes references to a larger
clinical dataset captured by the Registry which
aims to provide a picture of the care received
by people with IBD over time. We hope the
results and commentary prove of interest to
clinicians and others involved in managing
IBD, as well as to the 500,000 people living
with these diseases.
“Finally, the IBD Registry would like to thank
all those who have contributed to making this
report a reality, above all our partner IBD clinical
teams around the country who provided the
information on which the report is based.”
The report will be available on the IBD Registry
website as a PDF at www.ibdregistry.org.uk
Join our ‘Sock It to Sepsis’ campaign to
raise funds for vital research into sepsis.
Bring family & friends together and hold a stripy
or red and white themed event. Register today
for a Free fundraising pack.
Email: info@sepsisresearch.org.uk
Call: 07379 989 191
Together we can Sock it to Sepsis.
#stopsepsisnow
www.sepsisresearch.org.uk
Sepsis Research (FEAT) SCIO is a registered charity
SC049399 and relies on the generosity of legacies and
donations to help fund research and awareness of sepsis
GASTROENTEROLOGY TODAY - AUTUMN 2019
23

From Norgine, the company that brought you
MOVIPREP
NEWS
® (Macrogol 3350, sodium sulphate, ascorbic acid, sodium ascorbate and electrolytes)
The first 1 litre PEG bowel preparation 1-3
Improve the efficacy
cut the volume
vs MOVIPREP ®1
PLENVU® PM/AM dosing was
superior to MOVIPREP® in the per
protocol population (successful
overall cleansing 97.3% vs 92.2%,
p=0.014)
Safety profile comparable to
MOVIPREP® 1,4-6
Powder for Oral Solution
PEG 3350, Sodium Ascorbate, Sodium
Sulfate, Ascorbic Acid, Sodium Chloride,
and Potassium Chloride
UK AND IE PRESCRIBING INFORMATION: Plenvu powder for oral solution
(Macrogol 3350 + Sodium ascorbate + Ascorbic acid + Sodium sulfate
anhydrous + Potassium chloride + Sodium chloride)
Please refer to the full Summary of Product Characteristics (SmPC)
before prescribing.
Presentation: Plenvu powder for oral solution is administered in two doses.
Dose one is made up of 1 sachet containing: macrogol 3350 100g, sodium sulfate
anhydrous 9g, sodium chloride 2g, potassium chloride 1g. Dose 2 is made up of
2 sachets (A and B). Sachet A contains: macrogol 3350 40g, sodium chloride 3.2g,
potassium chloride 1.2g. Sachet B contains: sodium ascorbate 48.11g, ascorbic
acid 7.54g.
Indication: For bowel cleansing in adults, prior to any procedure requiring a clean
bowel.
Dosage and administration: For oral use. Adults and elderly: A course of
treatment consists of two separate non-identical 500ml doses of Plenvu. At least
500ml of additional clear fluid must be taken with each dose. Treatment can be
taken according to a two-day or one-day dosing schedule. Two-day dosing schedule:
First dose taken the evening before the procedure. Second dose in the early morning
of the day of the procedure. Morning only dosing schedule: Both doses taken the
morning of the procedure. The two doses should be separated by a minimum of
1 hour. Day before dosing schedule: Both doses taken the evening before the
procedure. The two doses should be separated by a minimum of 1 hour. No solid
food should be taken from the start of the course of treatment until after the clinical
procedure. Consumption of all fluids should be stopped at least 2 hours prior to a
procedure under general anaesthesia or 1 hour prior to a procedure without general
anaesthesia. Children: Not recommended for use in children below 18 years of age.
Patients with renal or hepatic impairment: No special dosage adjustment is
deemed necessary in patients with mild to moderate renal or hepatic impairment.
GASTROENTEROLOGY TODAY - AUTUMN 2019
Patients should be advised to allow adequate time after bowel movements have
subsided to travel to the clinical unit.
Contraindications: Hypersensitivity to the active substances or to any of the
excipients, gastrointestinal obstruction or perforation, ileus, disorders of gastric
emptying (gastroparesis, gastric retention), phenylketonuria, glucose-6-phosphate
dehydrogenase deficiency, toxic megacolon.
Warnings and precautions: The fluid content of reconstituted Plenvu does not
replace regular fluid intake. Adequate fluid intake must be maintained. As with
other macrogol containing products, allergic reactions including rash, urticaria,
pruritus, angioedema and anaphylaxis are a possibility. Caution should be used
with administration to frail or debilitated patients, in patients with impaired gag
reflex, with the possibility of regurgitation or aspiration, or with diminished levels
of consciousness, severe renal impairment, cardiac failure (grade III or IV of NYHA),
those at risk of arrhythmia, dehydration or severe acute inflammatory bowel disease.
24
In debilitated fragile patients, patients with poor health, those with clinically significant
renal impairment, arrhythmia and those at risk of electrolyte imbalance, the physician
should consider performing a baseline and post-treatment electrolyte, renal function
test and ECG as appropriate.
Any suspected dehydration should be corrected for before use of Plenvu.
There have been rare reports of serious arrhythmias including atrial fibrillation
associated with the use of ionic osmotic laxatives for bowel preparation, predominantly
in patients with underlying cardiac risk factors and electrolyte disturbance.
If patients develop any symptoms indicating arrhythmia or shifts of fluid/electrolytes
during or after treatment, plasma electrolytes should be measured, ECG monitored
and any abnormality treated appropriately.
If patients experience severe bloating, abdominal distension, or abdominal pain,
administration should be slowed or temporarily discontinued until the symptoms
subside.
The sodium content, 458.5mmol (10.5g), should be taken into consideration for
patients on a controlled sodium diet. The potassium content, 29.4mmol (1.1g), should
be taken into consideration by patients with reduced kidney function or those on a
controlled potassium diet.
Interactions: Medicinal products taken orally within one hour of starting colonic
lavage with Plenvu may be flushed from the gastrointestinal tract unabsorbed. The
therapeutic effect of drugs with a narrow therapeutic index or short half-life may be
particularly affected.
Fertility, pregnancy and lactation: There are no data on the effects of Plenvu on
fertility in humans. There were no effects on fertility in studies in male and female rats.
It is preferable to avoid the use of Plenvu during pregnancy.
It is unknown whether Plenvu active ingredients/metabolites are excreted in human
milk. A risk to the newborns/infants cannot be excluded. A decision must be made
whether to discontinue breast-feeding or to abstain from Plenvu therapy taking into
account the benefit of breast-feeding for the child and the benefit of therapy for
the woman.
Effects on ability to drive and use machines: Plenvu has no influence on the
ability to drive and use machines.
Undesirable effects: Diarrhoea is an expected outcome.
Common: vomiting, nausea, dehydration. Uncommon: abdominal distension,
anorectal discomfort, abdominal pain, drug hypersensitivity, headache, migraine,
somnolence, thirst, fatigue, asthenia, chills, pains, aches, palpitation, sinus
tachycardia, transient increase in blood pressure, hot flush, transient increase in
liver enzymes, hypernatraemia, hypercalcaemia, hypophosphataemia, hypokalaemia,
decreased bicarbonate, anion gap increased/ decreased, hyperosmolar state.
Refer to the SmPC for a full list and frequency of adverse events.
UNITED KINGDOM:
Price and pack sizes: £12.43 (3 sachet)
Legal category: Pharmacy medicine
MA Number: PL 20011/0040
MA Holder: Norgine Pharmaceuticals Limited, Norgine House, Widewater Place,
Moorhall Road, Harefield, Uxbridge, UB9 6NS, UK
IRELAND
Legal category: Product subject to medical prescription which may be renewed
MA Number: PA 1336/005/001
MA Holder: Norgine BV, Hogehilweg 7, 1101CA Amsterdam ZO, The Netherlands
Additional information is available on request or in the SmPC. For
further information contact: Norgine Pharmaceuticals Limited, Norgine
House, Moorhall Road, Harefield, Middlesex, United Kingdom UB9 6NS. Telephone:
+44(0)1895 826606. Email: medinfo@norgine.com
Date of preparation: March 2019
Company reference: UK/PLV/0319/0147
United Kingdom
Adverse events should be reported. Reporting
forms and information can be found at
www.mhra.gov.uk/yellowcard. Adverse events should
also be reported to Norgine Pharmaceuticals Ltd on:
Tel: +44 (0)1895 826 606 Email: medinfo@norgine.com
References: 1. Bisschops R, et al. Endoscopy 2018; doi: 10.1055/a-0638-8125. 2. Schreiber S, et al. Endoscopy 2018; doi: 10.1055/a-0639-5070. 3. DeMicco MP, et al. Gastrointest Endosc 2018; doi: 10.1016/j.gie.2017.07.047. 4. PLENVU ® UK Summary of Product
Characteristics. October 2018. 5. MOVIPREP ® UK Summary of Product Characteristics. September 2018. 6. MOVIPREP ® Orange UK Summary of Product Characteristics. August 2017.
UK/PLV/0919/0180
Date of preparation: September 2019
Ireland
Healthcare professionals are asked to report
any suspected adverse reactions via HPRA
Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel:
+353 1 6764971; Fax: +353 1 6762517.
Website: www.hpra.ie; E-mail: medsafety@hpra.ie.
Adverse events should also be reported to Norgine
Pharmaceuticals Ltd on:
Tel: +44 (0)1895 826 606 Email: medinfo@norgine.com

NEWS
88mm x 247mm (PI) CMYK
UK AND IE PRESCRIBING INFORMATION: Moviprep and Moviprep Orange (Macrogol 3350,
sodium sulfate anhydrous, ascorbic acid, sodium ascorbate, sodium chloride and potassium
chloride)
PLEASE REFER TO THE FULL SUMMARY OF PRODUCT CHARACTERISTICS (SmPC) BEFORE
PRESCRIBING.
Presentation: Powder for oral solution contained in two separate sachets, A and B. Sachet A contains
macrogol 3350 100g; sodium sulfate anhydrous 7.5g; sodium chloride 2.691g and potassium chloride
1.015g. Sachet B contains ascorbic acid 4.7g and sodium ascorbate 5.9g. Uses: Bowel cleansing prior
to any clinical procedure requiring a clean bowel. Dosage and administration: For oral use. Adults
and Older People: A course of treatment consists of two litres of Moviprep / Moviprep Orange. A litre
consists of one sachet A and one sachet B dissolved together in water to make one litre of solution.
The reconstituted solution should be drunk over a period of one to two hours. This process should
be repeated with a second litre to complete the course. A further litre of clear fluid is recommended
during the course of treatment.This course of treatment can be taken either as divided or as single
doses and timing is dependent on whether the clinical procedure is conducted with or without
general anaesthesia as specified below: For procedures conducted under general anaesthesia:
1. Divided doses: one litre in the evening before and one litre in the early morning of the day of the
clinical procedure. Ensure consumption of Moviprep / Moviprep Orange as well as any other clear
fluids has finished at least two hours before the start of the clinical procedure. 2. Single dose: two
litres in the evening before the clinical procedure or two litres in the morning of the clinical procedure.
Ensure consumption of Moviprep / Moviprep Orange as well as any other clear fluids has finished
at least two hours before the start of the clinical procedure. For procedures conducted without
general anaesthesia: 1. Divided doses: one litre in the evening before and one litre in the early
morning of the day of the clinical procedure. Ensure consumption of Moviprep / Moviprep Orange as
well as any other clear fluids has finished at least one hour before the start of the clinical procedure.
2. Single dose: two litres in the evening before the clinical procedure or two litres in the morning of
the clinical procedure. Ensure consumption of Moviprep / Moviprep Orange has finished at least two
hours before the start of the clinical procedure. Ensure consumption of any clear fluids has finished
at least one hour before the clinical procedure. Patients should be advised to allow for appropriate
time to travel to the colonoscopy unit. No solid food should be taken from the start of the course
of treatment until after the clinical procedure. Children: Not recommended below 18 years of age.
Contraindications: Known or suspected hypersensitivity to any of the ingredients, gastrointestinal
obstruction or perforation, disorders of gastric emptying, ileus, phenylketonuria, glucose-6-phosphate
dehydrogenase deficiency, toxic megacolon which complicates very severe inflammatory conditions of
the intestinal tract including Crohn’s disease and ulcerative colitis. Do not use in unconscious patients.
Warnings and precautions: Diarrhoea is an expected effect. Administer with caution to fragile
patients in poor health or patients with serious clinical impairment such as impaired gag reflex, or with
a tendency to aspiration or regurgitation, impaired consciousness, severe renal insufficiency (creatinine
clearance

NEWS
Rare Disease Collaborative
Network for non-responsive
and refractory coeliac disease
By Dr Heidi Urwin Coeliac UK Research
Manager.
Do you have patients diagnosed with coeliac
disease who have ongoing symptoms
despite a gluten free diet? Specialist teams
led by Prof David Sanders in Sheffield and Dr
Jeremy Woodward in Cambridge, have been
approved by the NHS for a Rare Disease
Collaborative Network (RDCN) to provide
support with the diagnosis and care of those
difficult cases of non responsive (NRCD) or
refractory coeliac disease (RCD).
The RDCN will provide facilities for a national
registry for patients with refractory coeliac
disease, a reference diagnostic pathway and
will share experience to improve understanding
and management of this condition.
For the majority of people diagnosed with
coeliac disease, lifelong adherence to a strict
gluten free diet results in clinical and histological
remission. However, up to 30% of people with
coeliac disease may have ongoing symptoms
and or laboratory abnormalities, despite six to
12 months treatment with a gluten free diet.
When NRCD is suspected the original
diagnosis of coeliac disease needs to be
confirmed, followed by repeat gastroscopy
with duodenal biopsies.
Adherence to a gluten free diet varies from 42 to
91% and the most common cause of ongoing
symptoms will be due to gluten exposure
(inadvertent or purposeful). Other causes of
ongoing symptoms may be due to “super
sensitivity”, slow response to treatment, or other
pathologies eg microscopic colitis, pancreatic
insufficiency, Giardiasis, hyperthyroidism.
Patients may broadly fit into one of four groups
depending on the absence or presence of
persisting symptoms and villous atrophy:
Persisting
symptoms
Normal duodenal
histology
Persisting villous
atrophy
Group 1 Group 2
No symptoms Group 3 Group 4
• Group 1, consider other causes of ongoing
symptoms such as functional disorders,
small intestinal bacterial overgrowth (SIBO),
fructose or lactose intolerance.
• Group 2, having excluded ongoing exposure
to gluten, super sensitivity or a slow
response to treatment, consider RCD.
• Group 3, discharge to primary care and
offer annual review in line with NICE NG20.
• Group 4, discuss and explain ongoing
inflammation and the potential risk of long term
complications, consider further dietetic support.
Refractory coeliac disease is rare and
reported to affect between 0.3 to 4.0% of
patients with coeliac disease. It’s also likely
to be over diagnosed due to the difficulties
in differentiating between ongoing gluten
exposure, “super sensitivity”, slow responders
and true RCD.
There are two types of RCD, type 1 and type
2, which differ in presentation, diagnosis
and mortality. Detailed analysis of cell
populations in the duodenal mucosa using
immunohistochemistry and flow cytometric
analysis is required on fresh biopsy samples,
services which are offered via the specialist
centres in Cambridge and Sheffield.
GASTROENTEROLOGY TODAY - AUTUMN 2019
26

NEWS
Patients with RCD type 2 have an aberrant
population of intestinal intraepithelial
lymphocytes (IELs) that lack the usual
expression of CD3 and CD8 on the cell
surface but do express intracellular CD3.
The phenotype of this IEL subset is present
in the healthy population, uncomplicated
coeliac disease and RCD type 1, but at
lower frequencies to that found in RCD type
2. Therefore, clonality testing alone is not
an adequate indicator of RCD type 2, which
requires quantification of the aberrant IEL
subset within the small intestine.
What is the NHS England’s Rare
Diseases Collaborative Network (or
RDCN) for (Non-Responsive and)
Refractory Coeliac Disease?
Sheffield and Cambridge have been
approved as NHS England’s Rare
Diseases Collaborative Network (or RDCN)
for (Non-Responsive and) Refractory
Coeliac Disease. NHS England has also
recognised Sheffield as the lead centre
and Cambridge as the member centre for
this NHS E collaborative disease network.
Clinicians who have cases of suspected
refractory coeliac disease can contact
david.sanders@sth.nhs.uk or Jeremy.
woodward@addenbrookes.nhs.uk. These
two centres will provide clinical support at
the level that the referring clinician would
wish. This can be by reviewing notes,
histological review, telephone consultation
(with patient or clinician) or by seeing the
patient and assessing small bowel biopsy
for monoclonal lymphocyte population, as
well as endoscopic intervention (capsule
endoscopy or enteroscopy). This ensures
a comprehensive assessment which then
leads to discussions about therapeutic
options. Therapeutic intervention can
again be provided by the RDCN or
the referring site. The most important
issue is to ensure that patients have a
standardised care and that the RDCN
can support colleagues in a collaborative
manner. The RDCN will also create a
National Register to provide prospective
data on such patients, analogous to Small
Bowel Transplantation. This may allow
consideration for novel treatments such as
Interleukin-15 or stem cell transplantation
The prognosis of RCD type 2 is poor with
a five year survival of around 50%, largely
accounted for by progression to enteropathy
associated T-cell lymphoma (EATL) in 33%
– 67% of cases. In contrast, while RCD type
1 can progress to EATL, this is rare and the
corresponding five year survival is > 90%.
Transformation to EATL carries a very poor
prognosis with the majority dying within 8
months of diagnosis and a five year survival of
only around 10%.
Clinicians who suspect they have any cases
of refractory coeliac disease can visit the
Coeliac UK website for further information
www.coeliac.org.uk/RCD and contact david.
sanders@sth.nhs.uk or Jeremy.woodward@
addenbrookes.nhs.uk
Reference:
Baggus EMR, Hadjivassiliou M, Cross S et
al. How to manage adult coeliac disease:
perspective from the NHS England Rare
Diseases Collaborative Network for Non-
Responsive and Refractory Coeliac Disease.
Frontline Gastroenterology 2019; 0: 1-8. doi
10.1136/flgastro-2019-101191
Record breaking number
of children hospitalised for
eating disorders
Highest number of girls age 13-17
admitted for anorexia as experts warn
parents of social media and celebrity
idolisation
Public Health England has released its
report showing the trends in numbers of
hospital admissions as a result of eating
disorders in young people across England,
revealing that there were more admissions
in 2017/18 than in any of the preceding
years.
There were 2,196 hospital admissions
for eating disorder of children and young
people aged 10 to 24 years in 2017/18.
2,006 - an overwhelming 91%- of these
were of girls, and 1,326 of these were of
girls aged 13 to 17 years.
The report breaks the number of hospital
admissions down by specific age and
gender, and shows that across all ages,
more girls are admitted to hospital than
boys.
Admissions for girls aged just 10 years old
have increased by 146%, from 13 in 2013/14
to 32 last year and for 12 year old girls,
by 93% (from 60 to 116 in the same time
period).
The report states that although bulimia is
more common among children and young
people, it is anorexia which accounts for the
larger proportion of hospital admissions,
fueling concern from leading addiction
treatment experts at UKAT.
“Eating disorders in young people and
children in particular is extremely concerning
because they’re more likely to develop
extensive physical and psychiatric problems
in the long term as a result of their eating
disorder” suggests UKAT’s Group Treatment
Lead, Nuno Albuquerque, who has vast
experience of treating eating disorders.
He continues; “Unlike most other addictions
and disorders, the treatment cannot centre
around abstinence, because we need to
eat to live. Instead treatment is focused on
finding a balance in the relationship between
the person and food. For most, overcoming
eating disorders developed at such a young
age is an ongoing process, and for some, will
be something they live with- under controlled
behaviours learned from treatment- forever.”
UKAT has also revealed that last year, they
admitted more people for eating disorders
than ever before, and that this year, they’re
taking on average around 5 enquiries a day
from concerned parents; double what they
were receiving last year. They run a specialist
eating disorder treatment facility called
Banbury Lodge (www.banburylodge.com) in
Oxfordshire.
Public Health England’s report also raises
concern about hospital admissions in young
boys, showing that back in 2013/14, only 1
10 year old boy was admitted to hospital but
in 2017/18, there were 9 and for 14 year old
boys, 14 were admitted in 2013/14 which has
risen by 178% to 39 in 2017/18.
Nuno concludes; “We believe that social
media and celebrity idolisation has a lot to
do with the rise in eating disorders stemming
from body image issues, but there’s also
a much deeper societal issue with children
experiencing the deficit of attachment from
parents.”
GASTROENTEROLOGY TODAY - AUTUMN 2019
27

POSTERS
COLITIS ON CT – DOES THIS MEAN
Ramakrishnan S, Veglio-Taylor E, Ta
Department of Gastroenterology, Barnet Hospital, Royal Fre
GASTROENTEROLOGY TODAY - AUTUMN 2019
28
BACKGROUND:
Cross sectional imaging is commonly used to assess the
abdomen for a variety of symptoms. Colitis reported on CT has
become a frequent indication for lower gastrointestinal
endoscopy. The outcomes of performing colonoscopy for
radiology reported colitis is not clearly known.
METHODS:
Retrospective single centre study of patients referred for
colonoscopy with the indication ‘abnormal imaging.’
Data collected from all endoscopies between 12 month period
at Barnet General Hospital (September 2017 to August 2018).
Exclusion criteria:
1) Modality other than CT/CTVC
2) Overt colonic polyp/mass on CT
Analysis performed using chi-square and student T-test.
Fig.1 – Radiological evidence of colitis
249 patients (183 CT (73.5%), 66 C
(41.8%)) or local lymph nodes (37 (
RESULTS:
colonoscopy for CT evidence o
(87.6%)), fat stranding (88 (35.
Median time from CT to endoscop
56.5).
53 (21.3%) patients of the 249 wh
had completely normal lower GI en
uncomplicated diverticulosis, 11
(8.0%) haemorrhoids and 37 (14.9%
20 patients (8.0%) had endoscop
(6%) histological evidence of coliti
10 patients (4%) had confirmed I
(4 Ulcerative colitis, 6 Crohn’s dise
Fig.2 - Reported CT findings as indic
NUMBER OF PATIENTS
250
200
150
100
50
0
Mural Thickening
Fat Stranding
Inflammati
L
CT FINDING

POSTERS
INFLAMMATORY BOWEL DISEASE?
riq Z, King J, Patel RN, Besherdas K.
e London NHS Foundation Trust, London, United Kingdom.
on
TVC (26.5%)) underwent a
f mural thickening (218
3%)), inflammation (104
14.9%)).
y was 33 days (IQR 12.5 –
o underwent investigation
doscopy. 111 (44.6%) had
(4.4%) diverticulitis, 20
) colorectal polyps.
ic evidence of colitis; 14
s.
BD at 6 months follow up
ase).
ation for Colonoscopy
ocal Lymph Nodes
Fig.3 - Comparison of endoscopic diagnosis according to
CT features and blood results
CONCLUSIONS:
Normal Colitis Malignancy *p value
(n=53) (n=20) (n=21)
Age, mean 63.6 54.4 69.5

COMPANY NEWS
CANTEL CANEXIS INTEGRATED WORKFLOW
SOLUTION & LYNGSOE SYSTEMS X-TRACKING
WORKING IN PARTNERSHIP AT NHS LOTHIAN
Cantel and Lyngsoe Systems are pleased to announce they
have won a 7-year contract to supply NHS Lothian with new
cutting-edge software to help manage and track sterile assets
across the Health Board.
Cantel will be supplying their new CANEXIS Integrated Workflow
Solution which links data and decision-making to support the efficient
operation of your critical hospital departments. The fully integrated
solution brings together differing departmental software into one
powerful tool and is available for Endoscopy, Sterilisation & Surgical
departments. The system will launch within the sterile processing
department at the Royal Infirmary Edinburgh and extend out to
endoscopy, dental and local decontamination units and operating
theatres throughout the Health Board. Lyngsoe Systems will be
supplying the X-TRACKING Location Tracking Software which will
track and trace the RFID tagged surgical sets, endoscopes and
equipment kits as they move between the different hospitals and
storage facilities.
This project will be the first of its kind in Scotland to deliver a fully
integrated solution with GS1 Standards and provides NHS Lothian with
a powerful tool to maximise operational efficiency whilst maintaining
high standards of patient safety. Cantel and Lyngsoe Systems are both
experts within their fields and this combined solution helps the Health
Board manage their inventory of surgical instruments to ensure full
traceability and safety throughout the sterilisation and decontamination
processes. The ever-rising quantity of instruments and the increasing
variation of maintenance and sterilization procedures have made
the “traceability” issue one of the major topics in hospital quality
management.
Integration of these two software systems will provide full visibility
of tray sets, endoscopes and other sterile goods as they leave the
sterilisation and decontamination departments and record them arriving
at the remote storage facilities spread across the Health Board.
The X-Tracking software will also be used to help keep track of
the health boards large inventory of medical devices. The clinical
engineering team have already started deploying new RFID embedded
GS1 asset labels to their medical devices and will be integrating the
X-Tracking software with their Medusa asset management software.
About Lyngsoe Systems:
Lyngsoe Systems has been a world leader in the field of cutting-edge
electronic logistics control for over 40 years and is leading within
the radio frequency identification (RFID) technology. With a proven
record of accomplishment of more than 5000
installations in 60 countries, the Lyngsoe Systems
team can demonstrate extensive experience in
customer process knowledge, solution design,
software development, integration, service and
maintenance.
GASTROENTEROLOGY TODAY - AUTUMN 2019
About Cantel:
Cantel deliver a comprehensive range of infection
prevention products and services. Starting with
the solution you need most, from Procedure,
Manual Clean, Reprocess, Dry & Store solutions,
and Track & Traceability software, they help you
remove risk and streamline operational efficiencies
to optimise your success. Cantel provides
high-quality infection prevention solutions and
unsurpassed service, touching millions of patients
around the world each year.
Contact Lyngsoe Systems at:
Phone: +44 20 3630 1602
Email: healthcare@lyngsoesystems.
comhealthcare@lyngsoesystems.com
Contact Cantel at:
Phone: +44 1702 291878
Email: info@cantelmedical.co.uk
30

COMPANY NEWS
GASTROENTEROLOGY TODAY - AUTUMN 2019
31

Helicobacter Test INFAI ®
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• cost-effective CliniPac Basic version for hospital use
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