Gastroenterology

Identifying Cases Of Pernicious Anaemia For Offering Baseline/Surveillance Gastroscopies as per BSG Guidance - Service Development In Shropshire (2023)

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Type of publication:
Conference abstract

Author(s):
*Rafique H.; *Rugemintwaza J.; *Mostafa W.; *Smith M.;

Citation:
Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2023. Liverpool United Kingdom. 72(Supplement 2) (pp A178-A179), 2023. Date of Publication: June 2023.

Abstract:
Introduction Pernicious anaemia (PA) is associated with a higher risk of gastrointestinal malignancies. BSG guidance suggests baseline gastroscopies for individuals aged >=50 years with laboratory evidence of PA, with surveillance offered to those with high-risk chronic atrophic gastritis.1 Shrewsbury and Telford NHS Trust is not currently offering gastroscopies to patients with PA. Our aim was to identify cases of PA suitable for gastroscopies in line with BSG guidance, followed by implementation of pathways for prospective detection of similar future cases. Methods A list of patients who tested positive for intrinsic factor antibodies (IF Ab) or gastric parietal cell (GPC Ab) between 2017-2022 was obtained from the laboratory. Patients aged 50-70y were stratified into groups as follows: Positive IF Ab considered confirmed PA; positive GPC Ab with low B12 levels considered probable PA; positive GPC with historically normal B12 and no anaemia considered unlikely to be PA. Patients who had gastroscopy for any indication in the last 5 years were excluded. Results 50 cases that met the criteria for confirmed or probable PA were deemed suitable for baseline gastroscopy. Pathway for these patients will be agreed with the hospital governance and GP liaison teams and standard letters and information leaflets will be devised. Confirmed cases will be offered gastroscopy, while probable cases will be offered further testing with IF Ab. If diagnosis is confirmed, gastroscopy will be offered, whereas if IF Ab is negative, no further action taken if the B12 deficiency responds to oral supplementation. For prospective detection of future cases, clinical text will be added in all biochemistry reports with low B12 levels prompting clinicians to consider IF Ab testing if PA is possible in clinical context, with referral to gastroenterology for confirmed cases. Cases tested before 2017 who fit the above criteria will be identified. Conclusions The number of confirmed or probable cases of PA in Shropshire is relatively small and sets a realistic target for offering gastroscopies in line with BSG guidance. Similar initiatives across other trusts could identify cases of PA in the respective regions that could be suitable for baseline or surveillance gastroscopies, with prospective detection of future cases leading to better overall management of PA.

The Advanced Colonoscopy Skills Training Required For NHS Bowel Cancer Screening Accreditation: The Outcomes Of An Integrative Literature Review (2023)

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Type of publication:
Conference abstract

Author(s):
*Brayford P.

Citation:
Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2023. Liverpool United Kingdom. 72(Supplement 2) (pp A169), 2023. Date of Publication: June 2023.

Abstract:
Introduction NHS Bowel cancer screening colonoscopists are required to undertake accreditation for which there are well defined standards, but training to achieve these skills has not been clearly determined. An Integrative Review aimed to identify the training required for independent colonoscopists to develop the advanced skills necessary to achieve Bowel Cancer Screening Accreditation (BCSA). The findings were utilised to develop a training plan which could support independent colonoscopists achieve BCSA. Methods The Integrative Review (IR) utilised the secondary research process described by Whittemore and Knafl (2005) to synthesise and analyse a range of methodologically diverse studies. Key stages of this process included problem identification, literature search, data evaluation, data analysis, conclusion drawing and presentation. Electronic databases including CINHAL, MEDLINE and PubMed were searched in September 2020. The inclusion criteria were English language literature focused on training in the advanced colonoscopy skills from 2012 onwards, excluding beginner colonoscopy training. Results In total this generated 3548 papers of which 3476 were excluded. The full text of seventy-seven papers were screened, identifying twenty-three methodologically diverse papers, meeting the inclusion/exclusion criteria for critical evaluation and analysis within the IR. Five broad themes were found to contribute to the development of the advanced colonoscopy skills required for BCSA-See figure 1. Conclusions It was clear from the IR that training in polyp related skills and knowledge was vital for successful BCSA. In addition, selecting motivated, meticulous colonoscopists and focusing on individual learning needs along with utilisation of audit and feedback all contribute to skill development for BCSA. The IR findings were utilised to develop evidence based individual, local, regional and national recommendations to assist with the advanced colonoscopy skill development necessary for BCSA.

Rectal cancer services - is it time for specialization within units? (2023)

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Type of publication:
Journal article

Author(s):
Maxwell-Armstrong, Charles; *Cheetham, Mark; Branagan, Graham; Davies, Justin; Davies, Mike; Eardley, Nicola; Hancock, Laura; Harikrishnan, Athur; McArthur, David; Siddiqui, Shahab; Tiernan, Jim; Torkington, Jared.

Citation:
Colorectal Disease. 25(7):1332-1335, July 2023

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The analysis of gut microbiota in patients with bile acid diarrhoea treated with colesevelam (2023)

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Type of publication:
Journal article

Author(s):
Kumar A; Quraishi MN; Al-Hassi HO; El-Asrag ME; Segal JP; Jain M; Steed H; Butterworth J; Farmer A; Mclaughlin J; Beggs A; Brookes MJ Authors Full Name Kumar, Aditi; Quraishi, Mohammed Nabil; Al-Hassi, Hafid O; El-Asrag, Mohammed E; Segal, Jonathan P; Jain, Manushri; Steed, Helen; *Butterworth, Jeffrey; Farmer, Adam; Mclaughlin, John; Beggs, Andrew; Brookes, Matthew

Citation:
Frontiers in Microbiology. 14:1134105, 2023. [epub ahead of print]

Abstract:
Introduction: Bile acid diarrhoea (BAD) is a common disorder that results from an increased loss of primary bile acids and can result in a change in microbiome. The aims of this study were to characterise the microbiome in different cohorts of patients with BAD and to determine if treatment with a bile acid sequestrant, colesevelam, can alter the microbiome and improve microbial diversity. Materials and methods: Patients with symptoms of diarrhoea underwent 75-selenium homocholic acid (75SeHCAT) testing and were categorised into four cohorts: idiopathic BAD, post-cholecystectomy BAD, post-operative Crohn's disease BAD and 75SeHCAT negative control group. Patients with a positive 75SeHCAT (<15%) were given a trial of treatment with colesevelam. Stool samples were collected pre-treatment, 4-weeks, 8-weeks and 6-12 months post-treatment. Faecal 16S ribosomal RNA gene analysis was undertaken. Results: A total of 257 samples were analysed from 134 patients. alpha-diversity was significantly reduced in patients with BAD and more specifically, in the idiopathic BAD cohort and in patients with severe disease (SeHCAT <5%); p < 0.05. Colesevelam did not alter bacterial alpha/beta-diversity but patients who clinically responded to treatment had a significantly greater abundance of Fusobacteria and Ruminococcus, both of which aid in the conversion of primary to secondary bile acids. Conclusion: This is the first study to examine treatment effects on the microbiome in BAD, which demonstrated a possible association with colesevelam on the microbiome through bile acid modulation in clinical responders. Larger studies are now needed to establish a causal relationship with colesevelam and the inter-crosstalk between bile acids and the microbiome.

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Intussusception of the appendix in a young adult: an important differential diagnosis of abdominal pain in cystic fibrosis patients? (2023)

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Type of publication:
Journal article

Author(s):
*Venkatasami, Meena; *Cobby, Ellen.

Citation:
Journal of Surgical Case Reports. 2023(3):117, 2023 Mar.

Abstract:
Cystic fibrosis (CF) is commonly associated with gastrointestinal manifestations from infancy to adulthood. Distal intestinal obstruction syndrome (DIOS) affects 20% of CF patients, where intussusception can be a rare complication. A 20-year-old CF male was diagnosed with a 3-day history of right iliac fossa pain and diarrhoea. Clinical examination revealed a tender palpable mass in the right iliac fossa and raised serum inflammatory markers. Contrast computerized-tomography of the abdomen-pelvis suggested intussusception of the appendix and further confirmed on histological analyses. The patient underwent an open appendicectomy where the intussusception had self-resolved. The literature review indicated a scarcity of data with 10 cases reported of intussusception in adult CF patients. Our case was in line with previous research of transient intussusception. This rare case highlights an importance to carry a higher index of suspicion for gastrointestinal manifestations in CF patients where differential diagnoses of DIOS and intussusception should be considered in the acute presentation.

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A Pilot Study on the Effect of Colesevelam on the Microbiome in Primary Terminal Ileal Resected Crohn's Disease (2023)

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Type of publication:
Conference abstract

Author(s):
Kumar A.; Quraishi M.N.; Al-Hassi H.O.; Elasrag M.; Segal J.P.; Jain M.; Steed H.; *Butterworth J.; Farmer A.; McLaughlin J.; Beggs A.; Brookes M.

Citation:
Journal of Crohn's and Colitis. Conference: 18th Congress of European Crohn's and Colitis Organisation, ECCO 2023. Copenhagen Denmark. 17(Supplement 1) (pp i532), 2023. Date of Publication: February 2023

Abstract:
Background: Surgery plays a pivotal role in ileal Crohn's disease despite the risk of endoscopic recurrence following an ileocaecal resection greater than 65% within 12 months of surgery. More than 90% of Crohn's patients have a concomitant diagnosis of bile acid diarrhoea following an ileal resection. This pilot study aimed to assess whether the use of bile acid sequestrants in post-operative Crohn's patients with bile acid diarrhoea can alter the microbiome and prevent disease recurrence. Method(s): Post-operative Crohn's patients with symptoms of diarrhoea underwent 75SeHCAT testing for bile acid diarrhoea. If positive (75SeHCAT < 15%), patients were treated with colesevelam and stool samples were collected at 4-weeks, 8-weeks and 6-12 months posttreatment. If negative (75SeHCAT > 15%), treatment was not given and were reviewed in clinic as per local guidelines. Patients underwent a 6-12 months post-operative colonoscopy where mucosal biopsies were taken. Disease activity was established using the endoscopic Rutgeert's score, with disease remission defined as Rutgeerts score < i2 and disease recurrence 3 i2. Faecal and mucosal 16S ribosomal RNA gene analysis was undertaken to assess a/b-diversity and microbial composition. Result(s): A total of 44 faecal samples and 44 mucosal biopsies were sequenced from 14 patients. 1/10 patients on colesevelam and 2/4 patients not on colesevelam demonstrated disease recurrence. There was no significant difference in a/b-diversity pre- and post-treatment. Pre-treatment, the three most abundant bacterial classes in all patients were Bacteroidia, Clostridia and Gammaproteobacteria (Figure 1). Following 6-12 months of treatment, out of the 9 patients on colesevelam, 5/9 (55.6%) had a reduction in Bacteroidia, 9/9 (100%) had an increase in Clostridia, and 7/9 (77.8%) had a reduction in Gammaproteobacteria. Of the two patients not given colesevelam, 1/2 (50%) showed a reduction in Bacteroidia, increase in Clostridia and a reduction in Gammaproteobacteria. Conclusion(s): This small pilot study demonstrated that patients who were given colesevelam, a bile acid sequestrant, were more likely to be in disease remission at their 6-12 months colonoscopy review. Furthermore, treatment with colesevelam may have a role in altering the microbiome to help maintain remission states in post-operative Crohn's disease. Larger mechanistic studies are now needed to confirm these findings and demonstrate statistical significance.

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Development and validation of a multivariable risk factor questionnaire to detect oesophageal cancer in 2-week wait patients (2023)

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Type of publication:
Journal article

Author(s):
Ho KMA; Rosenfeld A; Hogan Á; McBain H; Duku M; Wolfson PB; Wilson A; Cheung SM; Hennelly L; Macabodbod L; Graham DG; Sehgal V; Banerjee A; Lovat LB; SPIT Study Group Collaborators,. Included *Butterworth, J and *Button, H from Shrewsbury and Telford Hospital Trust as investigators

Citation:
Clinics and Research in Hepatology and Gastroenterology, 2023 Mar; Vol. 47 (3), pp. 102087

Abstract:
Introduction: Oesophageal cancer is associated with poor health outcomes. Upper GI (UGI) endoscopy is the gold standard for diagnosis but is associated with patient discomfort and low yield for cancer. We used a machine learning approach to create a model which predicted oesophageal cancer based on questionnaire responses. Methods: We used data from 2 separate prospective cross-sectional studies: the Saliva to Predict risk of disease using Transcriptomics and epigenetics (SPIT) study and predicting Risk of disease using detailed Questionnaires (RISQ) study. We recruited patients from National Health Service (NHS) suspected cancer pathways as well as patients with known cancer. We identified patient characteristics and questionnaire responses which were most associated with the development of oesophageal cancer. Using the SPIT dataset, we trained seven different machine learning models, selecting the best area under the receiver operator curve (AUC) to create our final model. We further applied a cost function to maximise cancer detection. We then independently validated the model using the RISQ dataset. Results: 807 patients were included in model training and testing, split in a 70:30 ratio. 294 patients were included in model validation. The best model during training was regularised logistic regression using 17 features (median AUC: 0.81, interquartile range (IQR): 0.69-0.85). For testing and validation datasets, the model achieved an AUC of 0.71 (95% CI: 0.61-0.81) and 0.92 (95% CI: 0.88-0.96) respectively. At a set cut off, our model achieved a sensitivity of 97.6% and specificity of 59.1%. We additionally piloted the model in 12 patients with gastric cancer; 9/12 (75%) of patients were correctly classified. Conclusions: We have developed and validated a risk stratification tool using a questionnaire approach. This could aid prioritising patients at high risk of having oesophageal cancer for endoscopy. Our tool could help address endoscopic backlogs caused by the COVID-19 pandemic.

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Treatment of portal vein thrombosis in cirrhosis: a multicenter real life cohort study (2023)

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Type of publication:
Journal article

Author(s):
Mantaka A; Gatselis N; Triantos CK; *Thalheimer U; Leandro G; Zachou K; Konstantakis C; Saitis A; Thomopoulos K; Kouroumalis EA; Dalekos GN; Samonakis DN

Citation:
Minerva gastroenterology. 69(1):107-113, 2023 Mar.

Abstract:
BACKGROUND: Portal vein thrombosis (PVT) is a common complication of cirrhosis and can be a cause or consequence of liver disease progression. It is unclear whether PVT treatment is affecting clinical outcomes in cirrhotics. METHODS: This is a multicenter study of cirrhotics with PVT, initially retrospectively and thereafter prospectively registered in a data base. We studied the impact of PVT treatment on this population for efficacy, safety and the impact on survival. In survival analysis Mantel-Cox and Wilcoxon-Breslow-Gehan tests were used. A P value of <0.05, was considered significant. For statistical computations the STATA 12.1 was used.

RESULTS: Seventy-six patients were included (76% decompensated, median MELD score 12 and Child-Pugh score 7), 47% with concomitant HCC. Fifty-one patients with PVT were treated with Vitamin-K antagonists or Low-Molecular-Weight Heparin. Patients were followed up for at least 6 months after PVT diagnosis, or until death or transplantation. PV patency after 6 months was not  statistically different between patients receiving or not anticoagulation (complete-partial recanalization 27.4% of treated vs. 20% of untreated, P=0.21). Median survival was statistically worse between patients treated with anticoagulation than those untreated (10 vs. 15 months, P=0.036). Less portal hypertensive bleeding and less decompensation rates were found in treated cirrhotics vs. untreated (45.8% vs. 54.2%, P=0.003 and 78% vs. 80.9%, P=0.78, respectively). Patients with HCC had worse survival when treated vs. untreated (P=0.047).

CONCLUSIONS: In our cohort of cirrhotics with PVT, treatment was feasible with acceptable side effects, but without meaningful clinical benefits.