Gastroenterology Today Summer 2021

Volume 31 No. 2
Summer 2021
Gastroenterology Today
What approach has 18 Week Support
taken with regards to building an
expert insourcing team?
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
18 Week Support Gastroenterology:
Partnering to Succeed
high-quality patient care, get in touch by calling on 020 3892 6162 or email Gastro.Recruitment@18weeksupport.com
Dr Matthew Banks
Clinical Lead for Gastroenterology

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CONTENTS
CONTENTS
Gastroenterology Today
4 EDITORS COMMENT
6 FEATURE Encouraging Uptake of Faecal Immunochemical
Tests (FIT) in Assessment of Patients with
Lower Bowel Symptoms
12 FEATURE Diagnosis and management of coeliac disease
in specialist paediatric gastroenterology centres
in the UK
14 FEATURE The incidence and prevalence of inflammatory
Matthew’s Perspective:
bowel disease in UK primary care: a
retrospective cohort study of the IQVIA Medical
Research Database
20 CASE REPORT Heavy metal in the gastroenterology clinic
22 CASE REPORT Infliximab-induced seizures in a patient
with Crohn’s disease: a case report
26 NEWS
30 COMPANY NEWS
This issue edited by:
Hesam Ahmadi Nooredinvand
c/o Media Publishing Company
Greenoaks
Lockhill
Upper Sapey, Worcester, WR6 6XR
What approach has 18 Week Support
taken with regards to building an
expert insourcing team?
ADVERTISING & CIRCULATION:
Media Publishing Company
Greenoaks, Lockhill
Upper Sapey, Worcester, WR6 6XR
Tel: 01886 853715
E: info@mediapublishingcompany.com
www.MediaPublishingCompany.com
Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. PUBLISHING He believes it starts DATES: with recruiting the
best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit March, clinicians June, whose JAG September performance data and is well December.
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
COPYRIGHT:
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 Media focus on Publishing NTS’. Company
Greenoaks
Tammy and Lisa’s Perspective:
Lockhill
Tammy Kingstree is Lead Nurse for Endoscopy.
‘It is extremely important that there are good working relationships within Upper the team. Sapey, This starts with Worcester, strong leadership WR6 from 6XR
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.
PUBLISHERS STATEMENT:
The views and opinions expressed in
this issue are not necessarily those of
the Publisher, the Editors or Media
Publishing Company.
‘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 Next Gastro.Recruitment@18weeksupport.com
Issue Autumn 2021
COVER STORY
In this edition we explore developments in CPD and education, in particular
how digital learning is contributing to the further development of technical
skills, diagnosis and disease management in endoscopy, all of which are vital
to quality, safety and efficiency.
Our JAG quality standards generally exceed the UK average (National
Endoscopy Database) but obviously no health organisation can afford to rest
on its’ laurels when it comes to quality and safety. This is why we have recently
partnered with GastroLearning, an endoscopic educational platform pioneered
by University College London consultants that delivers high-quality CPD and
educational content digitally.
All practitioners registered with 18 Week Support can access GastroLearning’s
education channels and content free of charge. In this post-pandemic world
the provision of education is changing fast. Formal conferences will continue
to have their place, but medical practitioners are increasingly switching to
content delivered across multiple digital channels that is directly relevant to
their need and which can be accessed at a time which best suits their busy
working lives. Read the article to see more about the content provided and
how it delivered free to any practitioner joining us here at 18 Week Support.
Subscription Information – Summer 2021
Gastroenterology Today is a quarterly
publication currently sent free of charge to
all senior qualified Gastroenterologists in
the United Kingdom. It is also available
by subscription to other interested individuals
and institutions.
UK:
Other medical staff - £18.00 inc. postage
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GASTROENTEROLOGY TODAY - SUMMER 2021
3

EDITORS COMMENT
EDITORS COMMENT
“The
pandemic
has
dramatically
changed our
practice. One
such change
has been a
shift toward
remote
consultations
which is, at
least in part,
here to stay.”
The incredible success of the COVID 19 vaccination has given us all hope. Although
most would agree this virus, like almost all others, will likely never be fully eradicated,
the success of the vaccination programme has meant a greater degree of freedom as we
gradually exit from lockdown. COVID 19 has not only affected the lives of our patients’
both physical and psychological wellbeing over the past sixteen months but the collateral
damage it has inflicted will likely be experienced for years to come. The measure of
the true impact of this is yet to be fully appreciated but given the reduction in access
to healthcare, it is inevitable that the delay in diagnosis and treatment is resulting in
increased morbidity and mortality for many patients particularly the elderly and those with
chronic conditions.
The pandemic has dramatically changed our practice. One such change has been a
shift toward remote consultations which is, at least in part, here to stay. This does not
only have the potential to improve the financial efficiency of our services but also many
patients prefer this to face to face consultation given the cost and inconvenience of travel.
Its success will however depend on being able to identify the group of patients for whom
remote consultation is appropriate and optimal as well as addressing digital literacy issues
particularly in the elderly.
Hesam Ahmadi Nooredinvand,
St George’s Hospital
GASTROENTEROLOGY TODAY - SUMMER 2021
4

WITH YOUR HELP
We’ve made
Gastroenterology a true
7 day NHS service
Join forces with the UK’s largest campaign to see and
treat those NHS patients who need you most. All working
as part of an expert clinical team in outpatient clinics or
undertaking Endoscopy procedures, getting the right care
to those patiently waiting.
Register your support or enquire below.
Together, we can end the wait.
www.ukmedinet.com

FEATURE
ENCOURAGING UPTAKE OF FAECAL
IMMUNOCHEMICAL TESTS (FIT) IN ASSESSMENT
OF PATIENTS WITH LOWER BOWEL SYMPTOMS
Keywords: Faecal immunochemical test (FIT), COVID-19, bespoke, FIT-KIT, triaging, endoscopy, waiting time.
Abstract
GASTROENTEROLOGY TODAY - SUMMER 2021
6
In April 2020, all non-urgent endoscopy procedures were
suspended due to the COVID-19 pandemic. Consequently,
those referred for colorectal cancer (CRC) investigation in
England under the NG12 1 and DG30 2 guidelines faced increasing
waiting times. It became necessary to triage these patients to
allocate resources effectively. However, the pandemic makes
patient contact challenging, reducing the number of face-toface
consultations to minimise the spread of COVID-19. Faecal
immunochemical tests (FIT) offer a unique solution since the
process can be managed “contact free”, reducing risk to patients
and health workers. Faecal sample collection by patients is still
novel, compared to other sample collection methods such as
for blood tests. However, patients are often reluctant to handle
faecal samples. A solution must, therefore, have a patient-centred
approach to encourage sample collection and return, while
ensuring good quality samples for analysis. The answer lies
in the provision of bespoke patient literature. Trust and Health
Board specific leaflets with local phone numbers, QR-codes,
barcodes, and clear visuals, with non-clinical instructional text,
provide much needed support to FIT pathways which, in turn, has
aided the management of endoscopy waiting lists. The bespoke
leaflets result in noticeable increases in return rates, and the
quality of samples received by laboratories are also much
improved.
The onset of the COVID-19 pandemic caused widespread disruption to
many clinical diagnostic pathways. Already overburdened endoscopy
services faced considerable reductions, resulting in fewer procedures
and, in consequence, fewer diagnoses of colorectal cancer (CRC) and
other significant bowel diseases. CRC is highly treatable if detected in
its early stages 3 and long-term quality of life is much improved following
successful treatment. However, the waiting times for endoscopy have
resulted, and still are resulting, in concerning delays to diagnosis 4 .
Therefore, a supporting pathway is a necessary prerequisite to alleviate
pressure on the service and prioritise those with the most severe
symptoms for further investigation.
Use of FIT
It is widely appreciated that FIT is the ideal tool to use, not only to
continue supporting the existing primary care pathways, as guided by
NICE NG12 1 and DG30, 2 but also for use in secondary care and triaging
patients on waiting lists. National guidelines published in both England 5
and Scotland 6 outline how FIT can be used to support CRC referrals in
the pandemic, by using higher faecal haemoglobin concentration (f-Hb)
thresholds than that recommended originally for the low-risk cohort
under DG30. 2
The f-Hb is proportional to the risk of severe disease and has been
proven to be a valuable marker even in those referred with rectal
bleeding 7 , suggesting that FIT is suitable in both high- and low-risk
patient groups. This is further supported by recent diagnostic accuracy
studies, highlighting that the negative predictive value (NPV) for CRC
is over 98.9% 8 even when using a high threshold of 150 µg Hb/g
faeces. Other possible thresholds for investigation have been very
recently documented in detail 9 . However, ubiquitous use of FIT in the
triage for further investigation of patients presenting with symptoms
is still relatively novel in terms of sample collection and logistics, so,
while technically FIT is a suitable test, its application must be carefully
managed to ensure the issues with overburdened services are resolved,
and not just relocated.
Managing Remote Sample Collection
GP consultations dropped by 30% between the end of March and end
of May 2020 10 , and primary care is the most common starting point
for referral for patients with suspected CRC. With this decrease, there
was concern surrounding the use of FIT and how well clinical pathways
could be supported. To address this, innovative logistics strategies
were required because good engagement is a key driver to motivating
patients to collect and sample faeces and return these samples for
analysis. Since telephone and video consultations increased sharply, it
was considered that the FIT sample collection device and instructions
for use, could be posted out to the patient, as well as being collectable
at the GP surgery. After the sample is collected by the patient, the
device is either posted back to the laboratory or dropped off at the GP
surgery for onward transport. These approaches make the complete
process between consultation and the generation of a result “contact
free” and therefore considerably reduces the risk of spreading
COVID-19. With the sample collection, handling, transport, and
other logistics now in place, encouraging correct use is clearly a vital
consideration.
Maximising Uptake
With such reliance on samples collected by patients, uptake is vital. With
faecal samples, there are the associated “fear” and “disgust” factors
which deter some patients from collecting the sample, in spite of the

FEATURE
simple, easy to use, hygienic FIT sample collection devices. However,
bespoke instruction for use (IFU) leaflets have been hugely influential in
increasing uptake and improving sample quality. Such IFU are based
around core sampling requirements but adapted to suit the specific
clinical pathway adopted by Trusts and Health Boards. With local
contact numbers, bar-codes, and detailed pathway information, patients
are made to feel included in the diagnostic process and are provided
with the tools to complete the sample collection successfully or talk to a
knowledgeable professional should they have any questions. IFU have
evolved over time, after initially being used in primary care, FIT is now
being used in a more diverse range of patients, 11 so the detail must be
regularly reviewed to ensure suitability. Usability studies, consultation
events, focus groups and feedback from cancer charities all could
contribute to the design and production of these IFU to maximise the
inclusivity of the process.
The design and application of sample collection devices are suited
to patient-based sampling and, although the attributes will not be
discussed in detail here, research has been conducted on the efficacy
of FIT in the hands of patients, 12,13 , proving them suitable for this
application. Additionally, the IFU provide supporting information such
as tips for collecting the faeces prior to using the device, which helps
familiarise using faeces as a sample and helps break some of the
barriers to the sampling process. It also helps reduce contamination risk
in terms of the faecal sample, and the sample collection device.
FIT for All
The last, and possibly most critical, barrier to uptake, is ensuring the IFU
are suitable for a range of patient groups. With FIT now being used in a
diverse range of patients, the bespoke literature must be as inclusive as
possible, ensuring patients can understand and follow the instructions.
As discussed above, the use of simple colourful pictures or diagrams
and text help those with visual impairments, or those for whom English
is not a primary language, and the additional information provided, such
as phone numbers, links to videos and websites, provide more routes
for patients to access help should this be required. It is important to
consider that a FIT device should not be simply handed to a patient with
no advice: as part of the safety-netting process, FIT should be provided
following a discussion with the patient.
Large, full-colour pictures with accompanying text provide patients
with user-friendly guidelines on the collection of faeces, using the
sample collection device to take the sample, and then how to return it
for analysis. Additional information should be provided on the clinical
pathway, why the test has been requested, and who to contact if
the patient has questions. These personalised aspects reduce the
unpleasantness associated with faecal sample collection. Their
introduction has resulted in an increase in return rate facilitating a
service to maximise impact and alleviate some waiting times.
Quality Samples
Any pathway involving a patient collected sample must yield samples
suitable for analysis. With FIT, there has been much scrutiny over the
use of a patient utilised sample collection device and the possible
impact on the laboratory result and, therefore, on patient outcome. The
primary consideration here is that FIT should never be used in isolation
and should be a tool applied in conjunction with clinical suspicion
and adjunct tests including the full blood count and iron studies when
appropriate, to further reduce the risk of missing CRC, particularly in
complex patients on waiting lists. 11
Concerns around patient sampling include over-sampling, undersampling
(or even, not sampling at all and providing an unused device
for testing). Contaminating the faeces prior to sampling with, for
example, menstrual blood and toilet cleaners can also be an issue.
To ensure continued relevance in the pathway, IFU are continuously
reviewed. Involvement with patients, key opinion leaders, and
feedback from laboratories all contribute to the ongoing improvement
programmes. Ensuring fidelity to the Trust or Health Board’s specific
clinical pathway helps the laboratories manage the samples effectively,
reducing the risk of overburdening the analytical capability. Feedback
is positive, with many reports showing over 90% of patients have been
able to follow the IFU and use the device as intended. 14
Logistics
The initiation of the use of FIT following the design of an IFU includes
the logistics: some encourage the GP surgery to hold stock of the
FIT-KITs (device, plus IFU, plus return envelope) so distribution is
managed on a local level, whereas others (particularly those with
electronic test requesting) have a centralised location from which the
FIT-KITs are distributed. Both models work for their respective users,
with stock management and logistics managed in a similar way to other
consumables, slotting into already proven processes.
Sample return logistics are also well studied. Originally, postal
return services, similar to the methods used in the bowel screening
programmes conducted in all four nations of the UK, was preferred,
reducing the footfall in GP surgeries, and giving patients a quick and
convenient sample return method. The ambient temperature stability
of any haemoglobin present after collection of faeces means a postal
return service would be a suitable route for sample returns. However,
due to cost implications, the return of samples via the GP surgery is
becoming more popular, negating the postage costs. Samples can be
efficiently and effectively returned to the laboratory with other types of
specimens via existing transport services. There has been no reduction
GASTROENTEROLOGY TODAY - SUMMER 2021
7

FEATURE
in patient uptake in those Trusts and Health Boards that have moved
from postal to GP surgery return, showing that FIT pathways can be
flexible and adaptable to local requirements.
Conclusion
Without doubt, the COVID-19 pandemic has fundamentally changed
many clinical pathways in the health service. Many hope that some of
these innovative changes will continue into the future. This the widely
held opinion regarding the application of FIT, and the recent expansions,
past the original NG12 1 and DG30 2 guidelines, to use FIT in all patients
of all ages presenting with lower bowel symptoms, has provided a
clinically relevant investigation which now is a vital tool in the diagnosis
and treatment of CRC. With new logistics options, patient-centric
literature, and a sample collection device specifically designed for
patient-based sampling, the expansion of FIT will continue to support
endoscopy service for years to come, by helping avoid unnecessary
procedures, and allowing urgent referral for those most at risk of
significant bowel disease.
FIT-KITS have been developed by Alpha Laboratories, working in
collaboration with a large number of NHS and private healthcare
providers across the UK. If you would like to discuss your requirements
to facilitate an efficient process for rolling out FIT for your patients,
please contact digestivedx@alphalabs.co.uk.
With thanks to Professor Callum G Fraser, Centre for Research into
Cancer Prevention and Screening, University of Dundee.
References
1. NICE. Suspected cancer: recognition and referral. NICE guideline
[NG12]. Last updated: 29 January 2021. https://www.nice.org.uk/
guidance/ng12 (Accessed 19 March 2021).
2. NICE. Quantitative faecal immunochemical tests to guide referral
for colorectal cancer in primary care. Diagnostics guidance [DG30].
Published date: 26 July 2017. https://www.nice.org.uk/guidance/
dg30 (Accessed 19 March 2021).
3. Colorectal Cancer Survival by Stage - NCIN Data Briefing. http://
www.ncin.org.uk/publications/data_briefings/colorectal_cancer_
survival_by_stage (Accessed 19 March 2021).
4. Ho KMA, Banerjee A, Lawler M, Rutter MD, Lovat LB. Predicting
endoscopic activity recovery in England after COVID-19: a national
analysis. Lancet Gastroenterol Hepatol 2021 Mar 10:S2468-
1253(21)00058-3. doi: 10.1016/S2468-1253(21)00058-3. Epub
ahead of print.
5. https://www.england.nhs.uk/wp-content/uploads/2020/10/
BM2025Pu-item-5-diagnostics-recovery-and-renewal.pdf (Accessed
19 March 2021).
6. https://www.gov.scot/publications/coronavirus-covid-19-guidancefor-use-of-fit-testing-for-patients-with-colorectal-symptoms
(Accessed 19 March 2021).
7. Digby J, Strachan JA, McCann R, Steele RJ, Fraser CG, Mowat C.
Measurement of faecal haemoglobin with a faecal immunochemical
test can assist in defining which patients attending primary care
with rectal bleeding require urgent referral. Ann Clin Biochem
2020;57:325-7. doi: 10.1177/0004563220935622.
8. D’Souza N, Georgiou Delisle T, Chen M, Benton S, Abulafi M;
NICE FIT Steering Group. Faecal immunochemical test is superior
to symptoms in predicting pathology in patients with suspected
colorectal cancer symptoms referred on a 2WW pathway: a
diagnostic accuracy study. Gut 2020 Oct 21:gutjnl-2020-321956.
doi: 10.1136/gutjnl-2020-321956. Epub ahead of print.
9. Mowat C, Digby J, Strachan JA, McCann RK, Carey FA, Fraser
CG, Steele RJ. Faecal haemoglobin concentration thresholds for
reassurance and urgent investigation for colorectal cancer based
on a faecal immunochemical test in symptomatic patients in
primary care. Ann Clin Biochem 2021 Jan 21:4563220985547. doi:
10.1177/0004563220985547. Epub ahead of print.
10. https://www.health.org.uk/news-and-comment/charts-andinfographics/non-covid-19-nhs-care-during-the-pandemic
(Accessed 19 March 2021).
GASTROENTEROLOGY TODAY - SUMMER 2021
11. Strachan JA, Mowat C. The use of faecal haemoglobin in
deciding which patients presenting to primary care require
further investigation (and how quickly) – the FIT approach.
eJIFCC 2021;32:52-60. https://www.ifcc.org/media/478839/
ejifcc2021vol32no1pp052-060.pdf (Accessed 19 March 2021).
12. Zahida Z, Carolyn P, Benton SC. Does visually over-loaded
HM-JACKarc collection device impact faecal haemoglobin
results? Ann Clin Biochem 2020 Dec 3:4563220976749. doi:
10.1177/0004563220976749. Epub ahead of print.
13. Benton SC, Symonds E, Djedovic N, Jones S, Deprez L, Kocna P,
Maria Auge J; International Federation of Clinical Chemistry Faecal
Immunochemical Test Working Group (IFCC FIT-WG). Faecal
immunochemical tests for haemoglobin: Analytical challenges
and potential solutions. Clin Chim Acta 2021 Feb 9;517:60-5. doi:
10.1016/j.cca.2021.01.024. Epub ahead of print.
14. Alpha Laboratories Ltd. Bespoke patient packs help support cancer
testing progress in the South West. Leading Edge. Vol. 2020, No. 1.
http://files.alphalabs.co.uk/e-mags/Leading_Edge_2020_Issue_1/
page_5.html (Accessed 23 March 2021).
8

FEATURE
How can you reduce the risk to
your Crohn’s disease patients
of serious COVID-19 disease? 1
Prescribe
Entocort ® CR:
classified by the
BSG as lowest risk
of serious COVID-19
disease, compared
to higher-risk
prednisolone 1
Entocort ® CR: BSG-recommended control patients can count on 1–3
Entocort ® CR is indicated for the induction
of remission in adults with mild to
moderate active Crohn’s disease affecting
the ileum and/or the ascending colon. 4
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 sucroseisomaltase
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
50 capsules: £37.53. Packs of 100 capsules: £75.05. Legal
category: POM. Marketing Authorisation Holder: Tillotts
Pharma UK Ltd, The Stables, Wellingore Hall, Wellingore,
Lincoln, LN5 0HX. Date of preparation of PI: February 2020
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.
GASTROENTEROLOGY TODAY - SUMMER 2021
References: 1. Kennedy NA et al. Gut 2020; 0: 1–7. 2. Campieri M
et al. Gut 1997; 41(2): 209–214. 3. Lamb CA et al. Gut 2019; 0: 1–106.
4. Entocort ® CR 3 mg capsules – Summary of Product Characteristics.
Date of preparation: July 2020. PU-00377.
9

GASTROENTEROLOGY TODAY - SUMMER 2021
NHS trusts with:
2WW Urgent referrals
Routine referrals
ADVERTORIAL FEATURE
Surveillance cases
Bowel cancer screening services
18 WEEK SUPPORT & GASTROLEARNING:
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Additionally, we can support Direct Access
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Continuing Professional Development is an integral part of
a doctors life. Continuous learning in endoscopy is equally
important and furthers our technical skills, disease diagnosis and
management, decision making, recognition and avoidance of
complications, non-technical skills and ongoing care.
Criteria & Quality
We select Endoscopists with an endoscopy
orientated career path and performance
measures above the national average. JAG
audit data is constantly monitored to ensure
ongoing quality. Furthermore, we have a
Quality, safety and efficiency are central to our culture in 18 Weeks Support.
This is why we have partnered with GastroLearning, an endoscopic
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18 Week Support JAG quality standards generally exceed the UK
average (National Endoscopy Database) and our complications are
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education focussing on the following areas:
• Technical endoscopic skills
clinical governance department that is crucial
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to maintaining quality and safety but also
provides support to both Endoscopists and
the units within which we work.
• Endoscopic management of disease (guidelines and therapy)
Covid has changed how professional education is delivered
The Covid pandemic has acted as a catalyst for a change in the approach
to providing medical education. However, changes in medical education
were already happening long before it’s unwanted arrival. The current and
younger generations of doctors, surgeons and allied health professionals
are more than competent digital learners. Education through digital channels
can be tailored by content and delivered very flexibly. “Snack” learning has
become particularly popular - everything you need to know on a subject in a
concise, clear format delivered by an engaging educator. Today’s generation
of practitioners are now less likely to see value – or to justify - the time and
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that may or may not be relevant to their specific need or practice. The modern
approach in education is where GastroLearning excels.
We provide tailored solutions to manage
capacity from straight forward supply of staff
to a team based managed solution to a full
patient pathway including pathology review.
Our commitment to improving the
NHS Conference experience organisers must learn to adapt
Like the NHS Trusts we work with, patient
care is at the centre of everything we do. By
using any spare weekend capacity within a
Trust, the 18 Week Support insourcing teams
are able to see a high volume of patients
in a short space of time, in the familiar
surrounding of the NHS Trust.
Of course there is still a place for face-to-face conferences, both
from an educational and social networking point of view. Conference
organisers with an innovative and dynamic approach to education will
likely learn from the many new digital trends that have taken centrestage
in the past year. But some will not and will likely be less popular.
Whilst the past year has seen a plethora of digital learning events,
transplanting the traditional format of a conference online does not
work. Few can sit in front of a screen for an endless stream of lectures
for hours on end without interaction and there is little educational benefit
in doing so. Digital education is here to stay but it must be delivered in
an innovative fashion that meets the needs of the modern generation.
New ways of digital learning in CPD provision
An ethical company
We’re an ethical and transparent company
that’s financially accountable and financially
through a bespoke platform on iPad and, in November 2020, we
responsible. We’re committed to the NHS
10
and the delivery of high-quality care, and to
helping Trusts reduce RTT waiting times.
GastroLearning has been involved in the provision of Gastroenterology
education for over 10 years, most notably through running national and
international conferences. But we have always recognised the need to
modernise. For the past 3 years we have supplemented the traditional
face-to-face conference with the delivery of interactive digital education
launched our online platform which already has a global following.
Clinical team
All 18 Week Support Practitioners Access Free Education
Our weekly “Express Packages” published every Thursday provides a
selection of educational material utilising varying formats, from edited
video cases and 5 minute lectures to “Top Tips” presentations and
literature summaries. These Happy packages patient are aimed at covering important
topics in a concise fashion while catering for differing educational needs.
We also run a hugely popular 30 minute “Live Show” on the first
Wednesday of every month in which an expert is interviewed on a topic
relevant Who to we’re every Gastroenterologist. looking for The show is supplemented by
additional educational material to maximise the learning opportunities
We are interested in meeting with Consultant
and key topics are accompanied with interactive quizzes to reinforce the
learning.
Gastroenterologists,
Finally, we understand the
senior
importance
nurses
of social
and
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clinical
and are
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Twitter nurse is becoming specialists an increasingly throughout popular method the for UK. individuals to
access and share education. It provides the opportunity to receive “snack”
learning and key messages can be shared, reaching a global platform.
Our remuneration package is second to
none and is per session rather than per case
which allows our teams to work in a safe and
calm environment’
All practitioners registered with 18 Week Support are able to access all
of this education content free of charge.
A future of effective partnerships and even newer
technology
Ways in which CPD and its associated learning are delivered will
continue to evolve rapidly. Although digital approaches are already
the norm in many areas of medical education, there is an increasing
footprint of artificial intelligence and virtual reality in our day to day lives
About you
which provides immensely exciting possibilities to enhance education
further. GastroLearning and 18 Week Support will strive to be at the
forefront If you of have this and an ensure excellent high-quality NHS education record is delivered and to all of
its practitioners and to the wider gastroenterology community in the UK.
want to help clear NHS waiting list
backlogs, reduce RTT waiting times and
provide high-quality patient care, get in
If you have an excellent NHS record and want to help clear waiting
touch by calling on 020 3966 9081 or email
list backlogs, reduce RTT waiting times and provide high-quality
recruitment@18weeksupport.com
patient care, get in touch by calling on 0203 869 8790 or email us
Dr David Graham and Dr Matthew Banks
Join us: www.gastrolearning.com Follow us on Twitter: @Gastrolearn
at Recruitment.team@18weeksupport.com
Alternatively if you are procurer of 18 Week Support services,
please contact busdev@18weeksupport.com
18 Week Support
www.18weeksupport.com
Dr Matthew Banks Banks
Clinical Lead for Gastroenterology
18 Week Support
London 3rd Floor, 19-21 Great Tower Street, London EC3R 5AR
Birmingham Unit 25, Lichfield Business Village, The Friary WS13 6QG
GASTROENTEROLOGY TODAY - SPRING 2019

IDENTIFYING ATROPHIC
GASTRITIS WITH THE AID
OF GASTROPANEL ® FROM
BIOHIT HEALTHCARE
A first-line test to prioritise
gastroscopy referrals
FEATURE
BIOHIT HealthCare’s GastroPanel is a simple and effective
first-line test to diagnose Helicobacter pylori (H. pylori) and
atrophic gastritis in patients presenting with dyspepsia and
upper abdominal symptoms. Where endoscopy resources are
overstretched and capacity is restricted, GastroPanel helps by
identifying those at greatest risk in a primary care setting prior
to referral.
Chronic H. pylori infection is the primary cause of atrophic
gastritis – a condition of the gastric mucosa considered to be
the greatest independent risk factor for developing gastric
cancer – and current guidance recommends that individuals
with extensive gastric atrophy undergo regular endoscopic
surveillance to closely monitor their disease progression.
Early detection of those individuals with a significant risk
of developing gastric cancer is the key to effective patient
management, helping to reduce unnecessary referrals, and
improving survival rates through earlier diagnoses.
GastroPanel comprises reliable and automatable assays
for four stomach-specific biomarkers, enabling thorough
and objective investigation of the whole gastric mucosa, and
offering clinicians more confidence in their diagnoses. The
highly specific IgG antibody test for identifying H. pylori is
combined with the analysis of pepsinogen I, pepsinogen II and
gastrin-17 to establish the structure and function of the entire
gastric mucosa. Implementing this first-line diagnostic test
can help to relieve the burden on overstretched gastroscopy
services, streamlining referrals for high-risk patients and
effectively ruling out gastrointestinal (GI) diseases for others.
This patient-friendly blood test can help transform the
referral pathway for upper GI investigations by aligning clinical
resources and identifying those in need of endoscopy at an
early stage, making it ideal for dyspepsia diagnosis.
GastroPanel is a simple, effective and low cost blood test for
assessment of the structure and function of the stomach in
patients with dyspepsia, helping the effective diagnosis of
chronic atrophic gastritis, acid output disorders, and other
diseases of the gastric mucosa resulting from a H. pylori
infection. It reveals the health and status of the gastric
mucosa, and provides information about the associated risks.
This enables the implementation of appropriate and effective
treatment plans, including eradication therapy, risk-based
referral for further investigation, and antacid prescription.
Key advantages of GastroPanel:
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gastritis, acid dysregulation, and H. pylori infection
• Patient and provider-friendly blood test for primary care
settings
• Guides patient management and referral to reduce waiting
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• Helps to identify patients most at risk of gastric cancer prior
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risk in a clinical setting, visit www.biohithealthcare.co.uk/GPblog
GASTROENTEROLOGY TODAY - SUMMER 2021
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11

FEATURE
DIAGNOSIS AND MANAGEMENT OF COELIAC
DISEASE IN SPECIALIST PAEDIATRIC
GASTROENTEROLOGY CENTRES IN THE UK
By Alice Andrews, Coeliac UK
Coeliac disease (CD) is a systemic autoimmune condition,
characterised by enteropathy of the small intestine, triggered
by dietary gluten in genetically susceptible individuals. CD
is estimated to affect 1% of the UK population however, only
around 30% of those with the condition have been diagnosed
[1]. The clinical presentation of CD varies from intestinal and
extraintestinal symptoms to asymptomatic presentations, making
diagnosis challenging for healthcare professionals.
Recent research published in the Journal of Pediatric Gastroenterology
and Nutrition has demonstrated excellent uptake of no-biopsy diagnosis
guidelines, but sheds light on variations in follow up care amongst 29
specialist paediatric gastroenterology centres in the UK [2].
Diagnosis via the no biopsy pathway
In 2012, European Society for Paediatric Gastroenterology, Hepatology and
Nutrition (ESPGHAN) revised guidelines to allow some children with CD to
be diagnosed without having a duodenal biopsy. Within these guidelines, a
no biopsy pathway was suitable for symptomatic children who:
• have IgA based anti-tissue transglutaminase antibodies (TGA-IgA)
>ten times the upper limit of normal
• positive anti-endomysial antibodies (EMA-IgA)
• Positive HLA-DQ2/DQ8 haplotype.
These guidelines have since been updated in 2020 with two notable
changes. Diagnosis can now be made without the need for HLA-DQ2/
DQ8 testing and secondly, a no biopsy approach can also be offered to
asymptomatic children [3].
NICE guidelines recommend that the need for a DEXA scan should
be considered on an individual basis at annual review [5]. A minority
(4/29) of centres reported that they performed routine DEXA scan post
diagnosis and some centres only offered a scan if there was a risk of
fractures or reported low vitamin D levels. Most children do not need to
have a DEXA scan as early diagnosis and adherence to the GFD has
been shown to improve bone density.
Most centres (28/29) routinely measured vitamin D status but practice
around supplementation varied. Most centres based their approach on
vitamin D levels, but in some centres vitamin D supplements are offered
to all CD patients regardless of their vitamin D status.
Since 2015, NICE guidelines have recommended that patients can
introduce gluten free (GF) oats to the diet at any stage [5]. GF oats add
variety to the gluten free diet and are also a good source of soluble fibre
but a small minority of people with CD are sensitive to GF oats. Less
than a third of centres recommended that children included GF oats
from diagnosis and the majority of centres waited until normalisation of
TGA-IgA before introducing GF oats to the diet [2].
New developments in paediatric coeliac
disease management
As there is limited research to inform the best management strategies,
current guidance is based on expert consensus opinion. There is a
need for more research in this area and an opportunity to undertake
prospective research to assess different follow up strategies.
An infographic summarising this publication is available at http://links.
lww.com/MPG/C303.
GASTROENTEROLOGY TODAY - SUMMER 2021
The survey carried out in 2019 concluded that in the UK, there was
excellent uptake of the ESPGHAN 2012 diagnostic guidelines, with 76%
centres (n=22) adopting the no biopsy pathway by 2013. Diagnosis
should only be made by a paediatric gastroenterologist or consultant
paediatrician with a special interest in CD however, at some UK centres
the diagnosis is made by a general paediatrician [4] or an expert dietitian.
Follow up care
The research also investigated follow up care and found discrepancies
across the UK [2]. Adopting a gluten free diet (GFD) is challenging
for children and their families as they face several difficulties, from
the increased cost of gluten free staple foods to school meals and
socialising with friends, which can all affect their quality of life and
adherence to the diet. For this reason, regular follow ups are important
for providing support and help maintaining adherence to the GFD.
References
[1] West, J. et al. (2019) “Changes in Testing for and Incidence of Celiac Disease in
the United Kingdom,” Epidemiology. Ovid Technologies (Wolters Kluwer Health),
30(4) e23–e24. doi: 10.1097/ede.0000000000001006.
[2] Paul, S. P. et al. (2021) “Celiac disease management in the United Kingdom
specialist pediatric gastroenterology centers – a service survey” Journal
of Pediatric Gastroenterology and Nutrition. 2021 Mar 17. doi: 10.1097/
MPG.0000000000003126.
[3] Husby, S. et al. (2019) European Society Paediatric Gastroenterology, Hepatology
and Nutrition Guidelines for Diagnosing Coeliac Disease 2020. Journal of
Pediatric Gastroenterology and Nutrition. 70(1):141-156. doi: 10.1097/
MPG.0000000000002497.
[4] Paul S. P. et al. (2019) “HLA-DQ2/DQ8 typing for non-biopsy diagnosis of
coeliac disease: is it necessary?” Arch Dis Child. 104:1119-20. doi: 10.1136/
archdischild-2019-317297.
[5] National Institute for Health and Care Excellence (2015). Coeliac disease:
recognition, assessment and management. NICE guidelines 20. NICE, London.
Available at https://www.nice.org.uk/guidance/ng20. [Accessed 27.04.2021]
12

Optimising
maintenance therapy
for ulcerative colitis:
Real
choices
When mesalazine doesn’t seem to be working, stepping
up to immunosuppressants isn’t the only option
Together we know more.
Together we do more.
FEATURE
Real
solution
Salofalk Granules are easy to take, they have a
pleasant vanilla flavour, and they’re a proven way to
help patients get the most from their mesalazine 1-3
Optimising therapy with once-daily Salofalk Granules in patients
who were inadequately maintained on previous mesalazine resulted in: 2
69% 45% 50%
fewer
days
off work
fewer
GP visits
due to UC
fewer
steroid
courses used
Mesalazine, the Dr Falk way
Prescribing Information (refer to full SPC before prescribing):
Salofalk gastro-resistant prolonged-release granules
Presentation: Stick-formed or round, greyish white gastro-resistant
prolonged-release granules in sachets containing 500mg, 1000mg,
1.5g or 3g mesalazine per sachet. Indications: Treatment of acute
episodes and the maintenance of remission of ulcerative colitis.
Dosage: Adults: Once daily 1 sachet of 3g granules, 1 or 2 sachets of
1.5g granules or 3 sachets of 1000mg or 500mg granules (equivalent
to 1.5 – 3.0g mesalazine daily) preferably taken in the morning,
according to individual clinical requirement. May be taken in three
divided doses (1 sachet of 500mg granules three times daily or 1
sachet of 1000mg granules three times daily) if more convenient.
Maintenance: 0.5g mesalazine three times daily (morning, midday
and evening) corresponding to a total dose of 1.5g mesalazine
per day. For patients known to be at increased risk for relapse
for medical reasons or due to difficulties to adhere to three daily
doses, give 3.0g mesalazine as a single daily dose, preferably in the
morning. Children: There is only limited documentation for an effect
in children (age 6-18 years). Children 6 years of age and older: Active
disease: To be determined individually, starting with 30-50mg/
kg/day once daily preferably in the morning or in divided doses.
Maximum dose: 75mg/kg/day. The total dose should not exceed the
maximum adult dose. Maintenance treatment: To be determined
individually, starting with 15-30mg/kg/day in divided doses. The
total dose should not exceed the recommended adult dose. It is
generally recommended that half the adult dose may be given to
children up to a body weight of 40kg; and the normal adult dose to
those above 40kg. Method of administration: Taken on the tongue
and swallowed, without chewing, with plenty of liquid. Contraindications:
Hypersensitivity to salicylates or any of the excipients.
Severe impairment of renal or hepatic function. Warnings/
Precautions: Blood tests and urinary status (dip sticks) should be
determined prior to and during treatment. Caution is recommended
in patients with impaired hepatic function. Should not be used in
patients with impaired renal function. Mesalazine-induced renal
toxicity should be considered if renal function deteriorates during
treatment. Cases of nephrolithiasis reported; ensure good hydration.
Patients with pulmonary disease, in particular asthma, should be
carefully monitored. Patients with a history of adverse drug reactions
to preparations containing sulphasalazine should be kept under close
medical surveillance. If acute intolerance reactions e.g., abdominal
cramps, acute abdominal pain, fever, severe headache and rash,
occur, stop treatment immediately. Severe cutaneous adverse
reactions (SCARs), including Stevens-Johnson syndrome (SJS) and
toxic epidermal necrolysis (TEN), have been reported. Discontinue
treatment at the first appearance of signs and symptoms of severe
skin reactions, such as skin rash, mucosal lesions, or any other sign
of hypersensitivity. Salofalk granules contain aspartame, a source of
phenylalanine that may be harmful for patients with phenylketonuria.
Salofalk granules contain sucrose: 0.02mg, 0.04mg, 0.06mg and
0.12mg (500mg/1g/1.5g and 3g granules respectively). Interactions:
Specific interaction studies have not been performed. Lactulose
or similar preparations that lower stool pH: possible reduction of
mesalazine release from granules due to decreased pH caused by
bacterial metabolism of lactulose. With concomitant treatment with
azathioprine, 6-mercaptopurine or thioguanine consider a possible
increase in their myelosuppressive effects. There is weak evidence
that mesalazine might decrease the anticoagulant effect of warfarin.
Use in pregnancy and lactation: There are no adequate data. Do
not use during pregnancy unless the potential benefit outweighs
the possible risks. Limited experience in the lactation period. Use
during breast-feeding only if the potential benefit outweighs the
possible risks; if the infant develops diarrhoea, breast-feeding
should be discontinued. Undesirable effects: Headache, dizziness,
peri- and myocarditis, abdominal pain, diarrhoea, dyspepsia,
flatulence, nausea, vomiting, aplastic anaemia, agranulocytosis,
pancytopenia, neutropenia, leukopenia, thrombocytopenia,
peripheral neuropathy, allergic and fibrotic lung reactions
(including dyspnoea, cough, bronchospasm, alveolitis, pulmonary
eosinophilia, lung infiltration, pneumonitis), acute pancreatitis,
impairment of renal function including acute and chronic interstitial
nephritis and renal insufficiency, nephrolithiasis, photosensitivity
especially with pre-existing skin conditions, alopecia, Stevens-
Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), myalgia,
arthralgia, hypersensitivity reactions such as allergic exanthema,
drug fever, lupus erythematosus syndrome, pancolitis, changes in
hepatic function parameters, hepatitis, cholestatic hepatitis and
oligospermia (reversible), asthenia, fatigue, changes in pancreatic
enzymes, eosinophil count increased. Legal category: POM. Basic
cost: Salofalk 500mg granules, pack size 100 sachets - £28.74;
31.47€. Salofalk 1000mg granules, pack size 50 sachets – £28.74;
32.87€. Salofalk 1.5g Granules, pack size 60 sachets - £48.85;
51.29€. Salofalk 3g Granules pack size 60 sachets - £97.70; 104.06€
(UK- NHS price; IE - PtW). Product licence number: Salofalk 500mg
granules – PL08637/0007; PA573/3/1. Salofalk 1000mg granules –
PL08637/0008; PA573/3/2. Salofalk 1.5g granules PL08637/0016;
PA573/3/7. Salofalk 3g granules PL08637/0025; PA573/3/6. Product
licence holder: Dr Falk Pharma GmbH, Leinenweberstr.5, D-79108
Freiburg, Germany. Date of preparation: November 2020
Further information is available on request.
GASTROENTEROLOGY TODAY - SUMMER 2021
Adverse events should be reported. Reporting forms and
information can be found at https://yellowcard.mhra.gov.uk/
(UK residents) or in Ireland at https://www.hpra.ie/homepage/
about-us/report-an-issue/human-adverse-reaction-form. Adverse
events should also be reported to Dr Falk Pharma UK Ltd at
PV@drfalkpharma.co.uk.
References:
1. Salofalk Granules. Summary of Product Characteristics.
2. Aldulaimi D et al. Poster DRF16/057 presented at the BSG
Annual Meeting, June 2016, Liverpool UK.
3. Keil R et al. Scand J Gastroenterol 2018; 21: 1-7.
UC: ulcerative colitis
13
Date of preparation: January 2021 DrF 20/226

FEATURE
THE INCIDENCE AND PREVALENCE OF INFLAMMATORY
BOWEL DISEASE IN UK PRIMARY CARE:
A RETROSPECTIVE COHORT STUDY OF THE IQVIA
MEDICAL RESEARCH DATABASE
Karoline Freeman 1* , Ronan Ryan 2 , Nicholas Parsons 1 , Sian Taylor‐Phillips 1 , Brian H. Willis 2 and Aileen Clarke 1
Freeman et al. BMC Gastroenterol (2021) 21:139 https://doi.org/10.1186/s12876-021-01716-6
Abstract
Background: Our knowledge of the incidence and prevalence of
inflammatory bowel disease (IBD) is uncertain. Recent studies reported
an increase in prevalence. However, they excluded a high proportion
of ambiguous cases from general practice. Estimates are needed to
inform health care providers who plan the provision of services for IBD
patients. We aimed to estimate the IBD incidence and prevalence in UK
general practice.
Methods: We undertook a retrospective cohort study of routine electronic
health records from the IQVIA Medical Research Database covering 14
million patients. Adult patients from 2006 to 2016 were included. IBD was
defined as an IBD related Read code or record of IBD specific medication.
Annual incidence and 12-month period prevalence were calculated.
Results: The prevalence of IBD increased between 2006 and 2016 from
106.2 (95% CI 105.2–107.3) to 142.1 (95% CI 140.7–143.5) IBD cases
per 10,000 patients which is a 33.8% increase. Incidence varied across
the years. The incidence across the full study period was 69.5 (95% CI
68.6–70.4) per 100,000 person years.
Conclusions: In this large study we found higher estimates of IBD
incidence and prevalence than previously reported. Estimates are highly
dependent on definitions of disease and previously may have been
underestimated.
Keywords: Inflammatory bowel disease, Primary health care,
Epidemiology, Electronic health care records
GASTROENTEROLOGY TODAY - SUMMER 2021
Background
Inflammatory bowel disease (IBD) includes a group of related, chronic
relapsing disorders. They place significant demand on healthcare
resources including consultation time, testing and treatment. In order
to plan healthcare resources, knowledge of the size of the problem
is required. This can be inferred from the incidence and prevalence
of IBD in the population. A recent systematic review published in the
Lancet assessed the incidence and prevalence of IBD around the
world [1]. Studies using UK data from the 1990s reported incidence
rates ranging from 21 to 32.2/100,000 [2–4] and prevalence estimates
ranging from 328 to 409/100,000 [2, 5–7]. The review suggested that
incidence rates have stabilised in the western world, while other studies
reported an ongoing increase in incidence rates [8, 9]. Two recent UK
studies, that excluded a high proportion of ambiguous diagnoses from
general practice, reported considerably higher prevalence estimates
of 725–781/100,000 [10,11]. A third recent study reported estimates
for ulcerative colitis and Crohn’s disease but excluded cases of IBD
unclassified (IBDU) [12]. However, IBD cannot be classified in 20–30%
of patients at first presentation and 13% remain unclassified 1 year
later [13]. This may have resulted in underestimates of the true IBD
prevalence in UK general practice. Our aim is to establish estimates of
incidence and prevalence of IBD in adult patients in UK general practice
using routine primary care electronic health records.
UK primary care data, such as the IQVIA Medical Research Database
(IMRD-UK) [formerly known as the Health Improvement Network (THIN)],
are unique and particularly suitable for research. Over 95% of the UK
population is registered with a GP [2, 14]. General practitioner (GPs)
act as gatekeepers to all services and specialists in secondary care
(excluding emergency care). Patients are usually only registered with one
GP at any one point in time; and for each patient the registration date
and the date when the patient leaves the practice is known. This provides
longitudinal data with known start and end date of follow-up. The role of
the GP extends to the management of chronic patients.
The IMRD population is broadly representative of the UK population and
prevalence of chronic diseases is comparable to national rates [15]. Findings
can be generalised to the broader UK primary care population [15].
Methods
Data source
Study data consisted of electronic health care records available in
the IMRD. The IMRD consists of anonymised, longitudinal individual
level patient data from more than 670 UK GP practices using the
Vision practice software. In 2015 a total of over 14 million patients had
contributed data to IMRD which reflects a coverage of about 6% of the
UK population [16]. Data are based on patient consultation information
including symptoms, diagnoses, investigations and medications recorded
as clinical codes. Data were included into the study from GP practices
from the date that the practice was deemed to be reporting all-cause
mortality reliably compared to national statistics and from 1 year after the
installation of the electronic medical record system. We applied these
quality control measures to ensure data reliability and completeness.
The IMRD has received Research Ethics Committee approval by the
NHS South-East Multicentre Ethics Committee for research as a whole.
Scientific Review Committees (SRCs) have been established to review
IMRD study protocols for scientific merit and feasibility. This project was
given approval by the SRC (SRC Reference Number 17THIN089) on
23rd October 2017.
14
*
Correspondence: k.freeman@warwick.ac.uk
1
Warwick Medical School, University of Warwick, Coventry, UK
Full list of author information is available at the end of the article

FEATURE
Study design and study population
We undertook a retrospective cohort study of patients with data in the
IMRD who were at least 18 years of age during the period 1 January
2006 to 31 December 2016. The study cohort was dynamic with patients
entering and exiting the study at different times. Patients entered the
study 1 year after they registered with the GP practice or at age 18 years,
whichever came later. Patients exited the study at the earliest of the
following dates: deregistration with the practice; death; or 1 January 2017.
Definition of IBD diagnosis
The outcome of interest was newly diagnosed IBD. We searched the
medical records of the study population for patients with a diagnosis of IBD.
Those with a clinical code indicative of IBD and/or at least one prescription
of an IBD specific medication in the patient record were classified as cases
of IBD. The date of IBD diagnosis was taken as the first occurrence of a
clinical code for IBD or first prescription of IBD specific medication in the
patient record. We were interested in the broad category of inflammatory
bowel disease and included clinical codes for general IBD, ulcerative colitis,
Crohn’s disease, indeterminate colitis and microscopic colitis. Clinical
code lists were adapted from those used in previous literature [6, 17].
IBD specific medication included mesalazine, olsalazine and balsalazide.
Sulfasalazine, prednisolone and budesonide preparations were considered
IBD specific if rectal. Preparations of beclometasone needed to clearly
specify use for the bowel to be included. Therefore, the definitions for
medications were purposefully narrow and decisions on inclusion were
exclusive if in doubt. The complete code list to identify IBD diagnoses is
available in Additional file 1.
Analysis
The annual incidence and 12-month period prevalence of IBD were
determined for 2006–2016 considering all adult patients contributing
data to IMRD in that period. Annual incidence was defined as the
number of new cases of IBD during a 1 year period over the total time
each patient was observed (person-time at risk). Period prevalence was
defined as new and pre-existing IBD cases during a 12-month period
over the number of patients in the IMRD database during the same time
period. Confidence intervals for incidence rates were exact Poisson
confidence limits. Confidence intervals for prevalence were calculated
using the Wilson procedure for proportions without a correction for
continuity. Incidence rates for male and female patients were compared
using the two sample z test.
All analyses were undertaken in R version 3.6.1 (Vienna, Austria)
[18]. The package “epitools” was used to calculate exact confidence
intervals for incidence rates [19]. Graphs were drawn using the package
“ggplot2” [20].
Results
IBD incidence and prevalence
We retrieved 6,965,853 records of adult patients from the IMRD
database and excluded 33,730 patients who entered the study after the
study period (Fig. 1). We included a total of 6,932,123 patients in the
analysis of IBD prevalence. The prevalence of IBD increased between
2006 and 2016 from 106.2 (95% CI 105.2–107.3) to 142.1 (95% CI
140.7–143.5) IBD cases per 10,000 in the adult IMRD population with
an average increase of 2.96% per annum. This amounts to an increase
of 33.8% from 2006 to 2016. More women than men had a recorded
diagnosis of IBD (Fig. 2).
We excluded 61,125 prevalent IBD cases from the dataset which
resulted in a dataset of 6,870,998 patients for the analysis of IBD
incidence (Fig. 1). There were 25,470 IBD incidence cases between
2006 and 2016. 4736 (18.6%) had an IBD Read code only, 9632 (37.8%)
had a prescription of an IBD medication only and 11,102 (43.6%) had
both. Incidence of IBD in the adult IMRD population varied across
the years with a maximum of 76.4 (95% CI 73.6–79.4) per 100,000
recorded in 2010 and the lowest incidence of 63.5 (95% CI 60.4–66.7)
per 100,000 recorded in 2016 (Fig. 3). The incidence across the full
study period was 69.5 (95% CI 68.6–70.4) per 100,000 person years.
The incidence rate was higher in women than men for the study period
(73.09 versus 65.83, z = 8.3, p < 0.0001).
GASTROENTEROLOGY TODAY - SUMMER 2021
Fig. 1 Overview of inclusion and exclusion of cases for the analyses of IBD incidence and prevalence
Fig. 1 Overview of inclusion and exclusion of cases for the analyses of IBD incidence and prevalence
15

FEATURE
Fig. 2 12‐month period prevalence of IBD per 10,000 adult IMRD population
Fig. 2 12-month period prevalence of IBD per 10,000 adult IMRD population
Discussion
Summary of study findings
The analyses of IBD prevalence and incidence included a total of
6,932,123 and 6,870,998 adult patients, respectively. The prevalence of
IBD in 2016 was 142.1 (95% CI 140.7–143.5) per 10,000 adult patients.
The prevalence of IBD increased between 2006 and 2016 by 33.8%.
This is likely due to the fact that IBD is a chronic condition which is
associated Fig. 2 with 12‐month a low mortality period prevalence rate. The of mean IBD per IBD 10,000 incidence adult IMRD for the population
study period was 69.3 (95% CI 66.8–71.8) per 100,000 person years.
The drop in incidence between 2010 and 2011 may be an artefact or
caused by an administrative change in coding/reporting standards.
Over the most recent 5-year period, the incidence of IBD was relatively
stable.
Study strengths and limitations
The IQVIA Medical Research database is a rich source of routine
electronic health care records of patients managed in primary care
and is particularly useful for the study of real world problems. The
study population was large and covered nearly 50% of all UK Clinical
Commissioning Groups [16] meaning that findings are generalisable to
UK primary care in general.
GASTROENTEROLOGY TODAY - SUMMER 2021
Fig. 3 Annual IBD incidence per 100,000 person‐years in the adult IMRD population
Fig. 3 Annual IBD incidence per 100,000 person‐years in the adult IMRD population
Fig. 3 Annual IBD incidence per 100,000 person-years in the adult IMRD population
16

FEATURE
The criterion “registration date plus 1 year” to assess patients’ eligibility
for study inclusion avoided the systematic over-reporting of incidence
rates in the first year of follow-up for newly registered patients [21]. It
also prevented the double counting of prevalent cases when patients
transfer from one IMRD practice to another.
Limitations that might have affected the research are linked to
characteristics of routine data.
IBD diagnoses might be missing either due to incorrect coding,
missed coding or recording as free-text. This might have led to an
underestimation of IBD incidence and prevalence. However, we
included a record of an IBD specific medication in the definition of an
IBD diagnosis which mitigated the effect. This may explain our higher
figures for IBD incidence and prevalence when compared to a recent
study which only included patients with two IBD Read codes recorded
or one IBD Read code and an IBD drug code [11].
Potential misclassification through miscoding of ulcerative colitis as
Crohn’s disease and vice versa, or by using higher order codes rather
than disease specific codes was of no consequence to our study. We
were interested in the broad category of inflammatory bowel disease
rather than sub-category, severity or location of disease. We were
able to include codes for IBD and indeterminate IBD and present the
complete picture of IBD in primary care which is in contrast to a recent
study which only focused on patients with a diagnosis of ulcerative
colitis or Crohn’s disease [12].
A limitation of our study may be our inability to verify IBD cases. While
we mitigated against under-coding, over-coding is a possibility. A study
reported that about 6% of IBD codes did probably not relate to a true
IBD diagnosis [6]. However, the study relied on confirmatory data from
GP questionnaires and considered coded data from 20 years ago.
Findings in the context of existing literature
Published figures on UK IBD incidence rates range from 21 to
37.5/100,000 [2–4, 10–12]. Studies consistently report that prevalence
is rising worldwide because of the low mortality associated with this
chronic condition. UK prevalence estimates range from 328/100,000 in
the 1990s [6] to 970/100,000 in 2017 [12].
Our estimates of incidence and prevalence of IBD in the UK are about
1.8 and 1.5 times higher than the most recent estimates. Published
studies are very heterogeneous, complicating comparison of reported
rates across studies. Major variations that explain at least some of the
differences include: (1) our study included adult patients only, while
the majority of other studies covered a wider age range including
children. This impacts the incidence and prevalence rates of IBD which
has an onset that peaks in adulthood. (2) Improvements in diagnostic
technology now enable the detection of milder cases [9]. (3)
Some smaller studies used GP records to identify cases with
subsequent exclusion of unverified cases. Exclusions ranged from 8
to 26% of patients [2, 3, 10]. This could have underestimated true IBD
prevalence. (4) Studies used different definitions of disease. A number
of studies did not include indeterminate IBD or microscopic IBD in
their definition. A recent study reported the incidence and prevalence
of ulcerative colitis and Crohn’s disease in the IMRD-UK database
[12]. The study only included Read codes for Crohn’s disease and
ulcerative colitis in the definition of disease. In contrast we used a very
comprehensive and sensitive list of Read codes and drug codes (48
codes) for the identification of IBD, ulcerative colitis, Crohn’s disease,
indeterminate IBD and microscopic colitis. In addition, a previous study
using the IMRD-UK data used a similar list of Read codes to our study
for the identification of IBD. However, they included non-specific IBD
medications to identify IBD cases and only included patients with at
least two subsequent IBD records or an IBD record and a recorded
prescription of an IBD related drug [11]. According to our data, this
approach may have missed at least 37.8% of cases. We were able
to increase the sensitivity of our Read code list by using medications
to identify additional IBD cases because we restricted inclusion of
prescriptions to IBD specific medications. This is an advantage of our
study over these two recent IMRD-UK studies.
Implications for research and practice
Taken together, the evidence suggests that the IBD incidence and
prevalence in the UK adult population may be higher than the latest
published figures. Some of the differences in reported rates may be
due to differences in methodology including differences in methods
of case definition [22]. Case definition is complicated by the fact that
IBD is a heterogeneous group of disorders. Crohn’s disease and
ulcerative colitis are considered as the two extremes of a spectrum
of chronic gut disorders [23]. Furthermore, the phenotype of IBD is
not uniform resulting in IBD unclassified cases [13, 24]. The overlap
with other infectious, inflammatory and autoimmune disorders led to
suggestions to diverge from the classification of IBD into ulcerative
colitis and Crohn’s disease and to reclassify IBD considering a broader
disease spectrum [25]. This argues for a broader definition of IBD in the
estimation of IBD incidence and prevalence.
Conclusions
In this large study we found higher estimates of IBD incidence and
prevalence than previously reported. Estimates are highly dependent on
definitions of disease and previously may have been underestimated.
We believe that our sensitive approach to identifying IBD cases may
be more reflective of the true burden of disease in UK general practice.
Health care providers who plan services for IBD patients need to make
allowances for these updated figures and should consider the definition
of disease in published studies.
Abbreviations
IBD: Inflammatory bowel disease; IMRD: IQVIA Medical Research
Database; THIN: The health improvement network; GP: General
practitioner; CI: Confidence interval; IBDU: IBD unclassified.
Supplementary Information
The online version contains supplementary material available at https://
doi.org/10.1186/ s12876-​021-​01716-6.
Additional file 1. Complete list of clinical and drug codes for the
identification of IBD diagnoses in electronic health records.
Acknowledgements
Not applicable
Authors’ contributions
KF, STP, BHW, RR and AC designed the study. RR extracted the data
from IMRD and created the datasets. KF and NP carried out the
analysis. KF, BHW, STP, NP and AC contributed to the interpretation of
the findings. KF drafted the manuscript. All authors read and approved
the final manuscript. KF takes responsibility for the integrity and
accuracy of the data analysis. KF acts as guarantor. The corresponding
author attests that all listed authors meet authorship criteria and that no
others meeting the criteria have been omitted.
GASTROENTEROLOGY TODAY - SUMMER 2021
17

FEATURE
GASTROENTEROLOGY TODAY - SUMMER 2021
Funding
KF is funded by a National Institute for Health Research (NIHR) DRF
award (DRF-2016-09-038) for this research project. AC is supported
by the National Institute for Health Research (NIHR) Applied Research
Collaboration (ARC) West Midlands. This report presents independent
research funded by the National Institute for Health Research (NIHR).
The views expressed are those of the authors and not necessarily those
of the NHS, the NIHR or the Department of Health and Social Care. The
funder had no role in the study design, data collection, data analysis
and interpretation, writing of the report or the decision to submit for
publication.
Availability of data and materials
The datasets generated during and/or analysed during the current study
are not publicly available under the data sharing agreement with the
University of Birmingham on behalf of IQVIA.
Declarations
Ethics approval and consent to participate
Anonymised data were provided by the data provider IQVIA. Studies
using IMRD have initial ethics approval from the NHS South-East
Multicentre Ethics Committee, subject to prior independent scientific
review. The Scientific Review Committee (IQVIA) approved the study
protocol (SRC reference number 17THIN089).
Consent for publication
Not applicable.
Competing interests
The authors declare: KF is funded by the NIHR through a doctoral
research fellowship. AC is supported by the NIHR ARC West Midlands
initiative. STP is funded by the NIHR through a career development
fellowship (NIHRCDF-2016-09-018). BHW reports grants from the
Medical Research Council. RR and NP have nothing to declare.
Author details
1
Warwick Medical School, University of Warwick, Coventry, UK.
2
Institute of Applied Health Research, University of Birmingham,
Birmingham, UK.
Received: 23 September 2020 Accepted: 10 March 2021
Published online: 26 March 2021
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Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
18

FEATURE
GASTROENTEROLOGY TODAY - SUMMER 2021
19

CASE REPORT
HEAVY METAL IN THE
GASTROENTEROLOGY CLINIC
Massardi C, Cooney J, Poullis A, Department of Gastroenterology, St George’s Hospital, London
Case Study
A 29-year-old male had attended the Emergency Department
on several occasions over the previous month with worsening
abdominal pain, constipation, nausea and vomiting. He had
no past medical or surgical history and worked as a builder
and decorator. There was no significant smoking or alcohol
history and he had no known family history of gastrointestinal
disease. Clinical examination was unremarkable. No cause
had been found for his symptoms so he was referred to the
Gastroenterology outpatient clinic.
Routine blood tests showed deranged liver function tests (LFTs), with
elevated bilirubin (31 umol/L) alanine transaminase (192 units/L) and
gamma-glutamyl transferase (65 iU/L) Autoimmune and viral liver
screens were negative. Ultrasound of the liver was normal apart from
some hyperechogeneity in the liver in keeping with fatty infiltration.
An abdominal radiograph was performed which found small specks
of high attenuation material in the colon [Figure 1]. A porphyria
screen was arranged due to the unclear aetiology of the patient’s
symptoms and blood tests.
The patient’s urine porphyria screen was found to be abnormal, with
a porphyrin/creatinine ratio of 472 nmol/mmol creatinine, therefore
further porphyria assays were requested.
GASTROENTEROLOGY TODAY - SUMMER 2021
These demonstrated a porphobilinogen of 27.8 umol/L (normal
limit

CASE REPORT
of toxicity. Clinical manifestations of lead toxicity are varied and can
be non-specific. Acute toxicity often manifests as abdominal pain,
constipation, body pains, decreased libido, headaches, memory
problems and irritability. Chronic exposure can produce anaemia,
reduced neuro-cognitive function, nephropathy, tremor, hearing loss
and hypertension 2 .
In the paediatric population lead toxicity risks significant and
irreversible neurodevelopmental damage and should be investigated
in any child presenting with an unexplained alteration in mental
state and behavioral changes in the presence of risk factors for lead
exposure 3 .
An elevated blood lead level reflects recent exogenous exposure as
well as release of endogenous lead from bone and soft tissue stores.
Toxicity is thought to develop due to lead competing with calcium in
several biological processes, inhibiting enzymes, and altering the
permeability of the blood brain barrier.
The mainstay of management is the separation of the patient from
the source of the lead exposure. In patient with very elevated lead
levels (>50 mcg/dL) or symptoms of acute toxicity chelation therapy
can be considered under specialist guidance 4,5 . The two most
commonly used chelating agents are DMSA (2,3-dimercaptosuccinic
acid) or EDTA (calcium disodium ethylenediaminetetraacetic acid).
Chelation should not be undertaken unless exposure to lead has
been curtailed, as in the presence of ongoing lead exposure,
chelation may lead to enhanced absorption of lead and therefore
worsening toxicity.
Regular and long-term monitoring of lead levels is required until
normal levels are achieved, as lead can be stored in bone for several
decades. Patients with established sequelae of lead toxicity such as
cardiovascular disease, cognitive dysfunction and renal failure are
unlikely to see reversibility of their symptoms over time even with
chelation therapy.
Conclusion
Lead toxicity is an uncommon yet important differential in patients
presenting with persistent abdominal pain. Prompt diagnosis and
subsequent treatment is imperative in negating the potentially long-term
damaging effects of lead on multiple organ systems. In these patients,
a through social history is the most crucial, but often overlooked, step in
reaching the diagnosis.
References
1. J. Route Reigart, British Medical Journal Best Practice
Guidelines; Approach to Lead Toxicity. Updated 17th April 2021.
https://bestpractice.bmj.com/topics/en-gb/755/diagnosisapproach#referencePop27
2. National Toxicology Program. Health effects of low-level lead
evaluation. Research Triangle Park, NC: US Department of Health
and Human Services; 2012. http://ntp.niehs.nih.gov/pubhealth/hat/
noms/lead/index.html
3. D. A. Gildow, Lead Toxicity, Occupational Medicine 2004;54:76–81
DOI: 10.1093/occmed/kqh019
4. Lin JL, Ho HH, Yu CC. Chelation therapy for patients with
elevated body lead burden and progressive renal insufficiency. A
randomized, controlled trial. Ann Intern Med 1999; 130:7.
5. Association of Occupational and Environmental Clinics. Medical
management guidelines for lead-exposed adults. April 2007. http://
www.aoec.org
6. Centres for Disease Control (CDC) and Prevention. Adult blood lead
epidemiology and surveillance (ABLES). http://www.cdc.gov/niosh/
topics/ables/description.html
Table 1: Risk Factors for Lead Exposure 1
Age
Pica syndrome
Housing environment
Occupation
Recreational activities
Traditional / herbal medicines
Children between the ages of 9-36 months are at the most risk of ingesting lead-containing substances in
their environment.
Compulsive ingestion of material with no nutritional value. Most commonly seen in children and pregnant
women.
Older homes (built before 1970) may have lead piping or lead paint.
Any job that involves handling material that may include lead, especially construction and decorating. The
risk is increased if the job entails sanding down walls or removing paint which generates a fine dust of lead
particles that are easily inhaled and ingested.
Including painting, figurine or jewelry making and stained glass making.
Any herbal remedy may contain lead. Most common sources are Ba- baw-san (traditional Chinese remedy
for colic), Daw Tway (used in Thailand and Burma as a digestive aid), Greta (traditional Hispanic remedy
for digestion or used during teething) and Ghasard (Indian folk medicine used as a tonic)
GASTROENTEROLOGY TODAY - SUMMER 2021
21

CASE REPORT
INFLIXIMAB-INDUCED SEIZURES IN
A PATIENT WITH CROHN’S DISEASE:
A CASE REPORT
Zhijie Lv 1 , Xiaoqi Zhang 2 and Li Wu 3*
Lv et al. BMC Gastroenterol (2021) 21:193 https://doi.org/10.1186/s12876-021-01780-y
Abstract
Background: Infliximab-induced seizures in patients with Crohn’s
disease are extremely rare and the mechanism of infliximab-induced
seizures is unclear.
Case presentation: A 60-year-old woman with Crohn’s disease
experienced infliximab-induced seizures, diagnosed on normal
magnetic resonance imaging of the brain. Moreover, the rechallenge
with infliximab was positive.
Conclusions: Neurological assessment and tight clinical monitoring
before and during therapy with infliximab should be performed in
patients with pre-existing seizure disorders.
Keywords: Infliximab, Seizures, Crohn’s disease, Case report
GASTROENTEROLOGY TODAY - SUMMER 2021
Background
Infliximab is currently used as the first-line treatment for Crohn’s
disease(CD). During the 20 years since its first approval in 1998,
infliximab has revolutionized the treatment of inflammatory bowel
disease(IBD). Over half a million patients have been treated with tumor
necrosis factor (TNF)-α antagonists, but concerns regarding their
safety have been raised worldwide [1].The most commonly reported
adverse reactions to infliximab include acute or delayed hypersensitivity
reactions; serious infections including reactivation of tuberculosis and
hepatitis B virus; malignancy, especially lymphoma and hematologic
reactions [2, 3]. However, new and rare side-effects have been
increasingly reported in post-marketing reports. Here, we have reported
a rare case of a patient with CD who experienced infliximab-induced
seizures, diagnosed on normal magnetic resonance imaging (MRI) of
the brain. Moreover, the rechallenge with infliximab was positive.
Case presentation
A 60-year-old female presented to our hospital with a 10-day history of
small intestinal stenosis due to CD. The patient was diagnosed with CD
in 2015 due to chief complaints of abdominal pain and watery diarrhea
(3−4 times per day). The patient’s medical history was unremarkable.
She was treated with mesalazine (3 g/day), which partially alleviated the
symptoms of abdominal pain and diarrhea (2−3 times per day). Ten
days before admission, she underwent colonoscopy, but it was difficult
to advance the colonoscope due to secondary intestinal stenosis. Biopsy
and three-dimensional computed tomography of the small intestine
confirmed the diagnosis of CD. Following admission to the hospital, a
series of related examinations were performed. Electrocardiography
revealed a normalized rhythm. Further evaluation revealed the following:
slight leukopenia (leukocytes count, 3.2 × 10 9 / L); serum albumin level,
36.1 g/L (normal range,40−55 g/L); platelet count, 123 × 10 9 / L (normal
range, 125−350 × 10 9 /L); serum calcium level, 2.18 mmol/L (normal
range, 2.25−2.75 mmol/L); fecal calprotectin level, 827.162 µg/g
(normal range 0−50 µg/g) and serum magnesium level, 0.82 mmol/L
(normal range, 0.7−1 mmol/L). T cell spot test for tuberculosis (T-SPOT.
TB) revealed negative findings. She also had no history of alcohol use
or drug abuse. Subsequently, treatment with infliximab was initiated
at a dosage of 5 mg/kg. She did not experience any side effects after
the first infliximab infusion. Two weeks later, she received the second
infliximab infusion (5 mg/kg), but after 5 days, she suddenly developed
short episodes of impairment of consciousness at home along with
limbs twitches and the extroversion of eyeball. During the episode, her
tongue was bitten, and her head was hurt. The episodes lasted for
approximately 3 min, and she was taken to a local hospital for treatment
by her family. However, she was not treated after observation at the
hospital (details unspecified). According to the schedule, the patient
received the third infliximab infusion at a loading dose of 5 mg/kg. She
experienced repeated episodes after 5 days of the third infusion. She was
taken to the local hospital, and craniocerebral CT showed no obvious
abnormalities. She was then admitted to the Department of Neurology
for further evaluation. Laboratory data showed normal findings, except a
high L-cholesterol level (3.35 mmol/L; normal range, 1.89−3.1 mmol/L)
and low lencocyte count (2.7 × 10 9 /L; normal range, 3.5−9.5 × 10 9 /L).
All physical examination findings were unremarkable. On the third day of
admission, she experienced another similar seizure episode. Therefore,
diazepam (5 mg) and sodium valproate(800 mg) were administered
intravenously to control the seizures. No recurrence was observed after
treatment during hospitalization. She underwent a brain 3.0 T magnetic
resonance angiography (MRA), which showed no apparent abnormality.
Video electroencephalography revealed background activity in the alpha
range with an amplitude reduction but a good waveform. On both sides of
the forehead and temporal area, scattered sharp waves were observed;
the waves were more obvious on the right side. During the monitoring
period, the patient was cooperative and did not show any behavioural
22
*
Correspondence: wulily525@126.com
3
Center of Clinical Evaluation, The First Affiliated Hospital of Zhejiang Chinese Medical University, 54 Youdian Road, Hangzhou 310006, Zhejiang, China
Full list of author information is available at the end of the article

CASE REPORT
Table 1 Summary of patient characteristics, seizures, and outcome
Features of
seizures
TNF-alpha
inhibitor
onset to
seizures
Inflammatory
disorder
Patients Age at
presentation,
gender
EEG CSF Other Treatment
for the
seizures
Seizures
outcome
Inflammatory
disorder
outcome
Repeated
episodes
each lasting
about 1 min
and followed
by several
periods of
generalized
tonic clonic
seizures
lasting more
than 6 min
Mild excess
slow wave
activity
Focal paroxysmal
activity
Normal MRI revealed
abnormal
T2 and fluidattenuated
inversion
recovery
signal hyperintensities
in a broadly
symmetrical
distribution
affecting the
cerebellar
hemispheres,
occipital
poles, medial
parietal
lobes, and
peripheral
frontal lobes
Not recorded MRI showed
encephalopathy
involving
mainly cortical
regions
TNF-alpha
inhibitor
stopped,
phenytoin
5 days after
the first
infliximab
administration
TNF-alpha
inhibitor
stopped
1 14, male Crohn’s
disease
Diffuse
nonspecific
cerebral
dysfunction
Not recorded MRI showed
scattered T2/
FLAIR signal
abnormalities
in the subcortical
white
matter predominantly
in the frontal
and posterior
parietal lobes
TNF-alpha
inhibitor
stopped
No more
seizures
occurred
No more
seizures
occurred
No more
seizures
occurred
Study author
and year
of publication
Remission for
6 months
and finally
relapse,
culminating
in colectomy
and ileostomy.
Zamvar,2009 [9]
Not recorded Brigo,2011 [10]
Not recorded Chow,2016 [12]
abnormalities. The Electroencephalogram (EEG) confirmed the diagnosis
of seizures and so far we highly suspected that the occurrence of the
seizures may be associated with the use of infliximab. The patient
Impairment of
consciousness,
amnesia
and arrest
of volitional
movements,
confusion
and disorientation,
aggressiveness
2 days after
the second
infliximab
administration
2 74, male Crohn’s
disease
Experienced 2
episodes of
generalized
tonic clonic
seizures
3 days following
the
second
infliximab
infusion
3 24, female Crohn’s
disease
started maintenance therapy with valproic acid (500 mg/day) and was
discharged after 6 days. Although there was a clear response to infliximab
with a reduction of diarrhoea and abdominal pain, the infliximab treatment
GASTROENTEROLOGY TODAY - SUMMER 2021
23

CASE REPORT
GASTROENTEROLOGY TODAY - SUMMER 2021
Table 1 (continued)
Study author
and year
of publication
Inflammatory
disorder
outcome
Seizures
outcome
EEG CSF Other Treatment
for the
seizures
Features of
seizures
TNF-alpha
inhibitor
onset to
seizures
Inflammatory
disorder
Patients Age at
presentation,
gender
Haddock,2011 [11]
was ceased and no seizures occurred after discharge. Now thalidomide
(25 mg/d) was used to maintain remission of CD. The patient was
following up for the moment.
Well controlled,
and no further
seizures
at two year
follow up.
Three focal
seizures post
discharge
TNF-alpha
inhibitor
stopped,
benzodiazepine,
phenytoin
Normal MRI showed
abnormal
high signal in
the subcortical
region,
bilateral
occipital
lobes, and
on the right
side with
extension to
involve the
right temporal
region
Right temporal
lobe dysfunction
Nausea, visual
disturbance,
unresponsive
dilated reactive
pupils,
bradycardic
and hypertensive.
13 days after
the first
infliximab
infusion
4 8, female Crohn’s
disease
TNF, tumor necrosis factor; EEG, electroencephalogram; CSF, cerebrospinal fluid; MRI: magnetic resonance imaging
Discussion and conclusions
Infliximab is a chimeric monoclonal antibody against the soluble and
the membrane tumour necrosis factor (TNF)-α [4]. It is effective in
inducing and maintaining remission in patients with moderate-to-severe
CD refractory to conventional therapy [5]. However, administration of
infliximab is associated with a well-recognized risk of infusion-related
adverse events, such as infusion reactions, autoimmune disorders,
malignancies, opportunistic infections, and serious infections [6]. The
neurological effects of infliximab have also been reported. Headache is
the most commonly reported, occurring in 12–18 % of patients studied
in the clinical trial setting [7]. The other commonly reported events
include peripheral neuropathy [8] and central nervous system and/
or spinal cord demyelination. Most patients have good tolerance to
infliximab; however, with its wide use in various autoinflammatory and
immune diseases, it is expected that more adverse drug reactions will
be reported in the future.
A literature review revealed that infliximab-related seizures have been
rarely reported (Table 1). In 2008, a 14-year-old boy with active CD
experienced probable occipital lobe seizures, followed by several
episodes of generalized tonic clonic seizures, 5 days after the first
infliximab administration [9]. In 2011, Francesco Brigo et al. [10] reported
a case of a 74-year-old man with CD who developed a sudden seizures
2 days after the second infliximab administration. His medical history was
notable for hepatitis C virus cirrhosis with normal liver function and for
an ischemic right temporo-occipital stroke, but he did not have a history
of previous seizures. Electroencephalography showed any paroxysmal
activity. In 2011, Rosemary Haddock et al. [11] reported a case of
posterior reversible encephalopathy syndrome in an 8-year-old girl with
CD after infliximab administration and colectomy. In 2016, Chow et al. [12]
reported a similar case of a 24-year-old woman who developed posterior
reversible encephalopathy syndrome(PRES) after the second treatment
with infliximab. Among the abovementioned, two cases occurred after the
second injection of infliximab, and two occurred after the first injection of
infliximab. There seemed to be no apparent consistency in the time of the
occurrence of the adverse reaction and definitely none of the patients had
a history of previous seizures.
In our case, there was a direct correlation between seizures and
infliximab administration. To the best of our knowledge, this is one of few
case reports of infliximab-induced seizures. In contrast to the previous
cases, our patient experienced the rechallenge events. Five days after
the second infusion, the patient experienced actually a seizure, just
failing to give enough attention. She again experienced seizures after
the third infusion. This positive rechallenge was the strongest proof
of side effects of infliximab. In the absence of infective, metabolic
encephalopathy and other known etiologies, symptoms regressed
quickly and completely. We also ruled out the possibility of seizures
caused by other drugs because no special drugs were administered
before the first three seizures except infliximab. MRA revealed no
abnormalities. Based on the video electroencephalography findings,
we speculated that the seizures were clearly associated with infliximabrelated
neurotoxicity. In previously reported cases, Posterior Reversible
Encephalopathy Syndrome (PRES) has been reported, but in our case,
both clinical symptoms and neuroradiological results were incompatible
with the diagnosis of PRES. Therefore, this case was different from the
other previously reported cases.
24

CASE REPORT
The mechanism of infliximab-induced seizures is unclear. However, it
may be due to the systemic pro-inflammatory effects of α-TNF agents
that cause an inflammatory response in the nerves [13]. Therefore,
infliximab should be cautiously administered to patients to minimize
possible morbidity for patients. Medication withdrawal is the first step
in managing patients with suspected drug-induced neuropathy [14],
The adverse events can occur in the initial stage of infliximab treatment
during induction phase. Moreover, all cases reported thus date had
no history of previous seizures and no other plausible cause of the
seizures. Consequently,we must underline the possibility of serious
and unexpected adverse reactions to infliximab, which are rare and
unpredictable. Considering the elimination half-life of infliximab (10
days), we should pay particular attention to the adverse reactions after
infliximab injection, especially before and after the second injection.
Various neurological complications such as demyelination and
peripheral neuropathy after treatment with TNF-α inhibitors have been
reported [14, 15]. For patients with a history of demyelination, seizures
or other serious neurological disorders, the use of TNF-α inhibitors
may increase the risk of exacerbation of neurological symptoms.
Neurological assessment and tight clinical monitoring before and
during therapy with infliximab should be performed in patients with
pre-existing seizure disorders. If absolutely necessary, prior assessment
and appropriate measures should be still taken before initiating therapy.
Further studies are still needed to evaluate the exact relationship
between infliximab and seizures.
Abbreviations
CD: Crohn’s disease; IBD: inflammatory bowel disease; TNF-α: Tumor
necrosis factor-alpha; MRI: Magnetic resonance imaging; MRA:
Magnetic Resonance Angiography; EEG: Electroencephalogram; CT:
Computed tomography; PRES: Posterior Reversible Encephalopathy
Syndrome.
Acknowledgements
All authors thank the patient for her support.
Authors’ contributions
LZJ performed the literature review. ZXQ collected the clinical data. WL
prepared the first version of the manuscript. All authors participated
in further drafting and revision of the manuscript. All authors read and
approved the final manuscript.
Funding
This research was funded by Health Commission of Zhejiang Province
(No.2020KY201) and Zhejiang Chinese Medical University (No.KC201936).
The funding bodies had no role in the design of the study and collection,
analysis, and interpretation of data and in writing the manuscript.
Availability of data and materials
This case report contains clinical data from the electronic medical record
in the Nanjing Drum Tower Hospital. The datasets used during the current
study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Authors’ institution does not require ethical approval for publication of
a single case report. Written informed consent was obtained from the
patient.
Consent for publication
Written informed consent was obtained from the patient for publication
of this case report and the accompanying images.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Pharmacy, Sir Run Run Shaw Hospital, School of
Medicine, Zhejiang University, 3 Qingchun Road, Hangzhou 310006,
Zhejiang, China. 2 Department of gastroenterology, Nanjing Drum Tower
Hospital, The Affiliated Hospital of Nanjing University Medical School,
321 Zhongshan Road, Nanjing 210008, Jiangsu, China. 3 Center of
Clinical Evaluation, The First Affiliated Hospital of Zhejiang Chinese
Medical University, 54 Youdian Road, Hangzhou 310006, Zhejiang,
China.
Received: 30 November 2020 Accepted: 20 April 2021
Published online: 27 April 2021
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14. Stübgen JP. Tumor necrosis factor-alpha antagonists and neuropathy. Muscle
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GASTROENTEROLOGY TODAY - SUMMER 2021
25

NEWS
National Report shows
Crohn’s and Colitis healthcare
urgently needs improvement
• Evidence from over 10,000 people with Crohn’s
or Colitis and 72% of specialist IBD health
services reveals that care across the UK is
costing some patients their health and the NHS
millions in unnecessary emergency treatment.
• COVID-19 has made worse issues such
as delays in diagnosis, long waits for
investigations and surgery, and little access
to much needed psychological and dietetic
support.
• Crohn’s & Colitis UK, the UK’s leading
charity for Crohn’s and Colitis, as part of
IBD UK, is calling for more resources and
support for services to deliver better care
for the half a million people living with this
complex condition.
• IBD must be recognised as an NHS priority
with a clear government strategy in all four
nations over the next 5 years.
A new report from IBD UK – a coalition of
leading health specialists in Crohn’s and
Colitis care, including charities, 17 professional
organisations and Royal Colleges - reveals
a UK-wide picture of IBD care which was
already stark prior to the COVID-19 pandemic.
The ‘Crohn’s and Colitis Care in the UK: The
Hidden Cost and a Vision for Change’ report 1
is the most comprehensive assessment of UK
care ever undertaken in the UK.
Sarah Sleet, CEO at Crohn’s & Colitis UK
and Chair of IBD UK summarises the current
state of play: “Crohn’s and Colitis are serious
conditions which aren’t taken seriously.
Unacceptably high levels of emergency
care and delays to diagnosis, investigations,
and surgery, exacerbated by the COVID-19
pandemic, are signs of services under
pressure and a model of care which is not
working. The report sets out a vision for
change – this needs to be prioritised by
governments across the UK and supported
with a defined long-term strategy.”
Diagnosis is taking too long
The report found that it is taking too long
for people with Crohn’s and Colitis to be
diagnosed, delaying their treatment and
support and resulting in potentially avoidable
flares and emergency care. Of over 10,000
people responding to the survey, a quarter
(26%) waited over a year for their diagnosis,
41% visited A&E at least once before
diagnosis, and 12% visited three times. For
everyone with Crohn’s and Colitis, almost three
quarters (72%) of admissions to hospital were
an emergency. This should not be the norm
for people with IBD. Not only does this have a
human health impact, but it is incredibly costly
to the NHS as the report showed that the cost
of managing someone in a flare is up to 6
times higher than when they are in remission.
Jacob is 19 years-old and lives with Crohn’s.
“Over 1–2 years before I was diagnosed, I
went to the GP several times. My diagnosis
was sudden and scary. At 4am one morning, I
was in terrible pain and couldn’t move an inch.
I felt like something inside was going to pop,
so an ambulance was called. I had a CT scan
which showed that my bowel was perforated
and I had contracted sepsis. I needed
emergency surgery, which resulted in a stoma
being formed to allow my bowel to rest... It had
a big impact on my mental health.”
Effects outside the gut are overlooked
Once diagnosed, care for people with Crohn’s
and Colitis is not proactive and is focused on
medication, rather than the wider impact of
the conditions. People are often left struggling
with severe pain, extreme fatigue, anxiety, and
problems outside the gut, with 89% of people
reporting they found it hard cope with having
Crohn’s or Colitis over the previous year.
Moreover, only 1 in 10 people (10%) said they
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NEWS
were assessed for how they had been coping
emotionally. Left unchecked and unchallenged,
we risk losing the potential of more future
generations of young people with IBD unable
to live fulfilling, productive lives.
People do not have access to a full range
specialist care
The report also found that people do not have
access to the full range of specialist care they
need. Most services are falling far short of
meeting the IBD Standards 2 recommendations
for crucial roles, including IBD nurse
specialists, dietitians, and psychologists. Less
than half (48%) of people felt their care was
coordinated with other specialist services.
The effects of Covid-19
Covid-19 has exacerbated issues which were
already stark prior to the pandemic, such as
delays in diagnosis, long waits for elective
care, surgery, and investigations, and little
access to multi-disciplinary teams. The report
shows that people with IBD cannot be left
behind as services rebuild post-Covid.
A vision for change
This coalition of experts in IBD care, wants
political decision makers across the four
nations to ensure that IBD is recognised as an
NHS priority with a clear government strategy
over the next 5 years.
In response to the findings from the report, Dr Ian
Arnott, IBD Section Chair at the British Society
of Gastroenterology says: “Despite fantastic
work to improve IBD care over the last couple of
decades, it’s clear that something fundamental
needs to change to deliver care that is more
personalised, preventative and proactive. It’s
time that IBD was recognised as the serious
condition it is, with appropriate prioritisation
and support provided to enable significant
improvements to be made across all services.
This comes at a pivotal moment as services
reconfigure in response to the COVID-19
pandemic. We can and we must do more to
ensure people with IBD receive safe, consistent,
high-quality, personalised care whatever their
age and wherever they live in the UK.”
www.crohnsandcolitis.org.uk
Footnotes:
1. IBD UK, ‘Crohn’s and Colitis Care in the UK:
The Hidden Cost and a Vision for Change’,
2021.
2. IBD Standards, IBD UK, 2019.
Coeliac UK poll highlights
concerns when eating out
post lockdown
• 36% of people said their biggest concern
was being an inconvenience 1
• Nearly half of people (48%) are worried
about being ‘glutened’ when eating at family
or friends 1
• 60% said they were less confident –
compared to before the lockdown – in
finding gluten free venues 2
In a recent poll by Coeliac UK, the national
charity for people with coeliac disease and
those who need to live without gluten, over a
third (36%) of people responding, said their
biggest concern when eating at a friend or
family’s house post lockdown, was about
being an inconvenience 1 .
Nearly half (48%) were most worried about
being accidentally ‘glutened’. A term used
by people diagnosed with coeliac disease
when they eat food that contains, or is crosscontaminated
with, gluten; a protein found in
wheat, barley or rye.
In another poll 2 nearly 60% of people said they
were less confident - compared to before the
pandemic - in finding gluten free venues post
lockdown.
Coeliac UK, aims to #ShineALightOnCoeliac in
a campaign running from 10-16 May 2021. The
campaign is focussing on the needs of children
and young people, by providing resources, tips,
recipes and advice for people when they are
eating away from home, which can be shared
with those catering for them, and in addition the
charity has launched a fundraising challenge to
raise £50,000 to support children with coeliac
disease in the future.
Hilary Croft, Coeliac UK CEO said: “Trusting
other people to provide gluten free food can
cause major feelings of anxiety and lead to
people avoiding social events. The last thing
anyone, let alone a young person needs now
is more isolation. So we are aiming to shine a
light on coeliac disease to make life better for
everyone who needs to live gluten free.”
Coeliac disease is not an allergy or an
intolerance but an autoimmune disease where
the body’s immune system damages the lining
of the gut when gluten is eaten. There is no
cure and no medication; the only treatment is
a strict gluten free diet. People diagnosed with
coeliac disease must maintain a strict gluten
free diet for the rest of their lives to reduce
the risk of very serious complications such
as osteoporosis, infertility and although rare,
small bowel cancer.
“As more people venture back out to eat at
their favourite restaurants, the poll results show
a worrying majority who are now less confident
about finding venues that offer safe gluten free
food. Before the pandemic, social distancing
and lockdowns there were venues across the
UK, accredited by Coeliac UK, serving safe
gluten free menu options. However, as we
know the hospitality industry has been severely
impacted by the pandemic, and we have
unfortunately seen closures and suspensions
of gluten free menus as the sector tried to
survive and weather the storm.”
“As lockdown eases, we are strongly
supporting our accredited partners to help
them continue to provide safe gluten free
options. Over the coming weeks and months,
we are preparing to shine a light on places
you can visit again, confident in the knowledge
of their commitment. And in the meantime,
to assist the community when eating out, we
have produced a handy pocket checklist of
things to ask venues both before and when
you visit them,” continued Ms Croft.
Coeliac UK’s Gluten Free Accreditation
programme provides customers with
assurance that they can enjoy safe gluten free
options and identify venues, which follow strict
procedures in food handling and ingredient
use, to ensure a safe gluten free experience.
1 in 100 people in the UK is estimated to
have coeliac disease but of these, only 30%
are currently diagnosed, meaning there are
nearly half a million people in the UK with
undiagnosed coeliac disease.
For more information about Coeliac UK
Awareness Week and the Challenge Week,
please see: www.coeliac.org.uk/shinealight
#ShineALightOnCoeliac
GASTROENTEROLOGY TODAY - SUMMER 2021
27

NEWS
EoS Network launches
ground breaking online
educational series for
patients, clinicians & the
general public
‘An urgent need to raise awareness of this
poorly understood condition’
To mark National Eosinophilic Awareness
Week, the charity EoS Network launched a
series of publicly available webinars to shed
light on Eosinophilic Gastrointestinal Disease
(EGID), an underdiagnosed set of chronic
conditions which affect the oesophagus and/or
lower gut and creates lifelong difficulties with
swallowing, eating and digestion.
Eosinophilic Diseases are immune-mediated,
most probably caused by food allergies or
other environmental triggers which occurs
in the upper gut (Eosinophilic Oesophagitis)
and/or the lower gut (Eosinophilic Gastritis,
Eosinophilic Gastroenteritis, Eosinophilic
Colitis).
In the most common of these conditions,
Eosinophilic Oesophagitis (EoE) this
immune response results in inflammation
of the mucosa in the oesophagus which,
if left untreated, can lead to oesophageal
remodelling including the formation of
strictures or furrows. In turn this creates
difficulties with swallowing certain foods or
tablets including food sticking or even food
obstructions. (SEE NOTES). In the UK it is the
single most common reason for emergency
admission to A&E for food bolus (obstructions)
removal. 1
Patients with EoE report living with constant
fear of choking, often avoid ‘tough’ ‘chewy’
foods and are embarrassed to eat with others
or in public due to coughing fits and/or
retching when food sticks. They often develop
avoidance tactics such as eating with lots of
water or eating very slowly. As a consequence,
understandably some develop anxiety around
eating and socialising.
Often misdiagnosed as GORD (gastrooesophageal
reflux disease) 2 or heartburn,
many sufferers go undiagnosed due to lack
of clinical and general awareness. Research
has found that the average time to receive a
diagnosis is around eight years 3
‘As a relatively newly recognised disease,
it is extremely important that we improve
eosinophilic gastrointestinal disease
awareness amongst the public, patients and
healthcare professionals,’ says Amanda
Cordell, CEO of the EoS Network. ‘These
webinars provide a valuable resource for
all these groups and feedback has been
extremely positive not only for patients but
also Health Care Practitioners (HCPs) who are
eager to learn more about this disease.’
The series of webinars, which have been
supported by the National Lottery Community
Fund in conjunction with government Covid
19 funding, are led by experts from across
the field of gastroenterology, dietetics and
allergy. They provide a complete overview of
Eosinophilic Oesophagitis, covering topics
such as the role of allergy in EoE, emergency
issues, long term management and dietary
solutions, along with information on paediatric
care and on the more complex EGIDs. They
will go live on the EoS Network website during
the Awareness Week and will be available for
anyone to access at www.eosnetwork.org
‘Along with these webinars, we also provide
educational tools, support and other resources
via our educational hub,’ explains Amanda. ‘In
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clinical papers and case reports or news that
you feel will be of interest to your colleagues.
Material submitted will be seen by those working within all
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All submissions should be forwarded to info@mediapublishingcompany.com
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NEWS
addition, we host a dedicated network section
for registered healthcare professionals from
around the world, allowing them to exchange
advice, research and support on treating these
unpleasant and life changing conditions.’
‘EoE is a chronic disease that, if left untreated,
can cause a severe food obstruction requiring
emergency medical removal. If you are having
the symptoms, we describe on our website
then you should discuss them with your GP
without delay.’
‘In the meantime, vital research continues into
the rarer, more complex lower gut eosinophilic
diseases which are severely life impacting,
an area where currently patients remain
desperate for emerging clinical guidelines and
treatments.’ 6
For more information or to interview
Amanda Cordell, please contact Graeme
Whitcroft at Healthy PR on 07793980500 or
GraemeWhitcroft@healthypr.co.uk
About the EoS network charity
The EoS Network works to ensure that every
person with an Eosinophilic Gastrointestinal
Disease receives a prompt accurate diagnosis,
the right treatment for them and support
to live with their condition. Its vision is for a
world where everyone with an Eosinophilic
Gastrointestinal Disease can eat without pain.
The EoS Network provides information and
support for patients and their families, a
global platform for clinicians and researchers,
educational resources and events and works
with medical bodies, manufacturers and
funders to ensure that the patient’s voice is
heard.
Notes on EoE
EoE is clinically characterized by oesophageal
dysfunction and histologically characterized by
an eosinophil-rich inflammation, most probably
caused by common food allergies or other
environmental triggers. Often misdiagnosed as
GORD, 2 adult symptoms include dysphagia,
bolus obstruction and chest pain related
to swallowing, heartburn and regurgitation.
In children they can include reflux-related
symptoms, nausea, vomiting, abdominal pain,
refusal to eat or failure to grow. 2 Untreated
EoE can lead to oesophageal remodelling
including the formation of strictures and EoE is
the cause of more than 50% of all emergency
presentations for oesophageal food bolus Current clinical guidelines can be found @
impactions. 1
https://www.eosnetwork.org/medicalguidelines
Annual incidence rates of EoE in western
countries are 10 per 100,000 with prevalence References
rates of 86 per 100,000. 4 However, for patients
with oesophageal symptoms who undergo 1. Prevalence of eosinophilic oesophagitis in
gastroscopy the prevalence is 7% whilst in
adults presenting with oesophageal food
patients with dysphagia and bolus obstruction, bolus obstruction. World J Gastrointest
prevalence increases to 23-50%. 1 Many
Pharmacol Ther 2015;6:244–247.
patients have a history of atopy, particularly Heerasing N, Lee SY, Alexander S, et al
asthma, allergic rhinitis and eczema. 5
2. Eosinophilic esophagitis N Engl J Med.
2015;373(17):1640–8. Furuta GT, Katzka
EoE only received classification in the 1990s DA.
and disease awareness, amongst both
3. Gastrointest Pharmacol Ther 2016; 7(2):
clinicians and the general public, is thought to 207-13. Ahmed M. World J
be low. Currently, average time to diagnosis 4. Limketkai BN et al Gut 2019 ; 68 : 2152-
is up to 8.1 years. 2 Due to the patchy nature 2160
of the disease, diagnosis requires 6 biopsies 5. Aliment Pharmacol Ther 2016; 43(1): 3-15.
to be taken from around the oesophagus
Arias Á et al
via endoscopy. Diagnosis is defined by 6. Eosinophilic gastrointestinal diseases
histological presence of eosinophils ≥15hpf. below the belt https://doi.org/10.1016/j.
jaci.2019.10.013 https://www.jacionline.
Treatment for EoE is focused around three
org/article/S0091-6749(19)31367-3/pdf
areas: dietary exclusion, drugs and dilatation. Pesek RD Rothernberg ME
Dietary exclusion is generally considered hard
to maintain and costly. Dilatation, ScheBo_GastroToday_Aug_2020 carried out Registered Multi-Ad_Address_Change
Charity 1143267
when the disease
has progressed
to oesophageal
strictures, is an
invasive procedure
which manages the
symptoms but not
the cause of EoE
and often has to be
repeated.
Until recently, all
drug treatments
were off-label and
topical steroid
therapy was not
optimised for delivery
to the oesophagus.
However, NICE
and the SMC have
now recommended
budesonide
orodispersible tablet
(Jorveza ®) for
active EoE in adults,
a treatment option
designed to reach the
area of inflammation
in the oesophagus
(final NICE guidance
due 23rdJune).
GASTROENTEROLOGY TODAY - SUMMER 2021
29

COMPANY NEWS
COST EFFECTIVE & USER FRIENDLY
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BIOHIT’S TEST PANEL FOR STOMACH
HEALTH BACKED BY FURTHER EVIDENCE
GASTROENTEROLOGY TODAY - SUMMER 2021
A recent study published by the research group of Professor
Francesco Di Mario at Parma University, Italy, found a strong
relationship between low levels of plasma Gastrin-17 (G-17)
and the manifestation of gastro-oesophageal reflux disease
(GORD). 1 These results add to the weight of evidence behind
GastroPanel ® , a test produced by BIOHIT Oyj, that includes
G-17 as one of three biomarkers used in combination with
a Helicobacter pylori IgG assay to distinguish the stomach
health of patients with gastrointestinal problems.
GastroPanel is designed for the first-line diagnosis of H. pylori infection
and atrophic gastritis in patients with dyspepsia or GORD. It is a
non-invasive blood test that offers an easy way to check the stomach
mucosa and gastric acid secretion in the patient. This can lead to an
informed decision of whether further examination is needed – usually by
gastroscopy – and ultimately to the early discovery and intervention of
gastrointestinal disorders.
Current UK guidelines recommend an H. pylori stool antigen test in the
care pathway of patients with gastrointestinal problems. However, this
test fails to show mucosal damage due to long-term infection, including
gastric atrophy (GA) or gastric intestinal metaplasia (GIM), both of which
are precursors to cancer. In addition to testing for H. pylori infection,
GastroPanel tests for three stomach-specific biomarkers – pepsinogen I,
pepsinogen II and G-17 – that provide more information than a stool test
alone, helping to non-invasively identify patients at risk.
Graham Johnson, Managing Director of BIOHIT HealthCare Ltd,
commented: “The results from this study showed that GORD patients
both in primary care, and those that had been referred, had statistically
significant lower levels of G-17 compared with the dyspeptic patients. 1
This confirms that the G-17 biomarker is a reliable predictor of GORD,
and further extends the scope of gastric diseases detectable with the
GastroPanel. We hope this helps to implement the wider use of the
GastroPanel, which is a proven, cost-effective strategy in screening
patients at risk of gastric cancer.”
For more information visit www.biohithealthcare.co.uk/gastropanel.
About BIOHIT Healthcare Ltd
BIOHIT Healthcare Ltd (www.biohithealthcare.co.uk) is part of the
Finnish public company, BIOHIT OYJ, which specialises in the
development, manufacture and marketing of products and analysis
systems for the early diagnosis and prevention of gastrointestinal
diseases. The company’s many unique and patented diagnostic
tests transform clinical practice and make screening, diagnosis and
monitoring of gastrointestinal diseases efficient and cost effective.
Non-invasive diagnostics are at the core of BIOHIT’s offering, making
it the provider of choice for leading gastroenterologists and laboratory
scientists worldwide.
References
1. Di Mario F, Crafa P, Franceschi M, et al. Low Levels of Gastrin 17 are Related
with Endoscopic Findings of Esophagitis and Typical Symptoms of GERD. JGLD
[Internet]. 12Feb.2021 [cited 11May2021];30(1):25-9. Available from:
https://www.jgld.ro/jgld/index.php/jgld/article/view/2952
30

COMPANY NEWS
POINT-OF-CARE CALPROTECTIN
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POSTER SUBMISSIONS
If you have submitted a poster to previous 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 - SUMMER 2021
31

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