LGP UPDATE ? March 2011 Tel: 020 8337 9609Page 1

The London Gastroenterology Partnership

UPDATE

UPDATE...Dr Penny Neild looks at some of the myths and rebuttals surrounding IBS and the evidence for diet changes in the management of symptoms

Everything you Need to Know about liver disease in

pregnancy. takes a look at pre-existing liver disease in pregnancy

Dr Tony Rahman

Dr Andy Poullis takes a look at probiotics and their evolving position in gastroenterology

Capsule Endoscopy Service

A capsule endoscopy service has been set up by London Gastroenterology Partnership at Alexander House, Wimbledon. The Consultant in charge is Dr Jin-Yong Kang, Consultant Gastroenterologist. Dr Kang also carries out NHS and private capsule endoscopy studies at St George's Hospital, Tooting.

For appointments at Alexander House contact: 020 8543 9098. For private appointments at St George's Hospital contact Dr Kang's private secretary at: 020 8339 9474

Capsule endoscopy is a non-invasive test for examining the small intestine. The main indications are gastrointestinal bleeding or iron deficiency anaemia of unknown cause and suspected Crohn's disease.

Making an Appointment To access all the services offered by the London Gastroenterology Partnership patients should contact the head office on Tel: 020 8337 9609. The office is open from 8.30am until 5pm Monday to Friday.

Continued overleaf...

Dr Jin-Yong KangMD PhD FRCP, FRCPEd, FRACP

Issue 2 - March 2011

In this edition of

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Read more below...

What is the evidence for diet in the management of Irritable Bowel Syndrome?

Introduction

Fibre

Anecdote vs Evidence……

with IBS. In consultation with patients about their IBS, invariably the subject of diet will arise, and indeed the contribution of food to Irritable bowel syndrome (IBS) is an extremely common symptoms is one of the most often discussed condition, affecting up to 19% of the adult population at any one subjects on IBS websites. So what is the objective time. Although only a third of people affected consult their GP, evidence for the role of diet, either in aetiology or IBS accounts for 12% of primary care caseloads and 28% of treatment of IBS?gastroenterology practice.

Diet has been proposed to play a role in the pathogenesis of IBS. Various food items have been implicated including lactose, fructose, wheat, and caffeine. Several mechanisms for food- Soluble fibre (primarily derived from the flesh of fruits and induced symptoms have been proposed and include food vegetables and grains) is effectively broken down and fermented by intolerance, food allergy, bacterial overgrowth, altered colonic enzyme producing bacteria present in the colon to produce short flora, as well as alterations in gastrointestinal physiology after chain fatty acids and gas. Stools are bulky, attributed to the increase eating. However, the importance of these mechanisms remains in bacterial mass of the stool. This fibre forms a gel-like substance unclear and response to dietary modification has been variable which can bind to other substances in the gut having additional and inconsistent. benefits of lowering cholesterol levels and slowing down the entry

of glucose into the blood thereby improving blood sugar control.

Insoluble fibre, derived from the skins and pips of fruit and vegetables and husks of grains etc, is less easily degraded by colonic Food-related gastrointestinal symptoms are common, even

within the general population and are reported in 50% of adults

LGP UPDATE ? March 2011 Tel: 020 8337 9609

bacteria but holds water very effectively (up there may be an increased level of sensitivity results of diet-related studies in IBS in the to 15 times its weight in water) thus to the ingestion of certain carbohydrates literature, it seems clear that diet is likely to contributing to an increase in stool weight. It and sorbitol. This should be considered in contribute, at least in part, to individuals' is this fibre that is often referred to as the dietetic treatment of IBS patients. symptoms and it is certainly of great "natures broom". importance to patients who attend clinics

in both the primary and secondary care Conclusions: The benefits of fibre in the setting. It is also clear that there is no 'one treatment of irritable bowel syndrome are size fits all' formula which can be Caffeine has been shown to stimulate marginal for global irritable bowel recommended, even for each subtype of colonic motor activity, to the same degree syndrome symptom improvement and IBS, though some general guidance as a meal and anecdotally, it appears to irr i tab le bowel syndrome-re lated regarding intake of fibre and carbohydrates increase symptoms in some patients with constipation. Soluble and insoluble fibres such as lactose, fructose etc could be IBS, particularly of the diarrhoea have different effects on global irritable offered. However, for individuals with predominant type. However, evidence bowel syndrome symptoms. Indeed, in some particularly troublesome symptoms and/or directly relating caffeine and gastrointestinal cases, insoluble fibres may worsen the concern about their diet, a dietitian should symptoms suffered by IBS patients is lacking clinical outcome, though this effect was not be involved, as the emphasis should be on in the literature.as prevalent in primary care. maintenance of as balanced and nutritious a

diet as possible within the bounds of necessity to restrict certain components, if clearly beneficial to symptoms.

Peppermint oil relaxes smooth muscle by Studies suggest that the presence of blocking calcium influx and therefore has intraduodenal fat may increase severity of antispasmodic properties. Because of this, IBS symptoms or exacerbate abdominal peppermint oil is frequently used to treat distension and potentially contribute to the IBS as well as dyspepsia. Although a number exaggerated gastro-colic reflex seen in such of studies have been performed, reporting individuals. modest benefit, efficacy remains unclear.

Findings suggest that, despite the lack of increased prevalence of malabsorption,

Despite the often seemingly contradictory

Caffeine

Peppermint Fat

Carbohydrates and Sorbitol S u m m a r y a n d o v e r a l l Conclusions

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Dr Penny Neild Bsc, MD, MB, ChB, FRCP

When confronting liver dysfunction in and infertility so pregnancy is infrequent. Autoimmune Hepatitis (AIH) - can patients in pregnancy it is important to have result in the cessation of menstrual cycles an understanding of normal physiological Viral Hepatitis and hence infertility. Treatment with low changes. doses of corticosteroids and azathioprin

Hepatitis B (Hep B) - The transmission rate maybe required to maintain remission. to the foetus during pregnancy is rare as the Stillbirths and premature labour can occur. placenta provides a barrier to infection. The most common time of vertical transmission As part of a normal pregnancy things go up is the time of delivery. The risk of and things go down!transmission is similar regardless of the mode of delivery (caesarean section or Decreased – Gall bladder contractility, vaginal delivery). Vaccinating the newborn levels of uric acid, albumin, total protein, These patients have normal liver function against Hep B can prevent infectivity at the protein S and antithrombin III. prior to pregnancy but develop coincidently time of delivery. The baby should receive

to pregnancy.Hep B vaccine and Hep B immune globulin Increased - Clotting factors, 3-4 fold (called HBIG) at birth. increase in alkaline phosphatase (ALP) due Viral Hepatitis

to placental production. Cholesterol, Hepatitis C (Hep C) - Chronic Hep C does caeruloplasmin, transferrin and alpha 1 and Acute viral hepatitis (A, B, C and E) can not normally cause any specific problems, 2 globulins may also be increased. develop coincidentally during pregnancy. however, there is a small chance (<6%) of foetal transmission. No Change - Aminotransferases (ALT,

·Gallstones - About 2% of women who AST, GGT), bilirubin (Bil) and prothrombin are pregnant develop gallstones during Mode of delivery does not influence the time (INR). pregnancy and in the post-partum rate of transmission. Breastfeeding is

period. Laparscopic cholecystectomy is encouraged, however, patients may avoid best performed in the second trimester.breastfeeding if their nipples are cracked or

bleeding.

Cirrhosis - Cirrhosis causes amenorrhoea

Normal

Liver diseases that develop during, but are not induced by Pregnancy

Pre-existing liver disease and pregnancy

Everything you needed to know - Liver disease in pregnancy

Continued overleaf...

LGP UPDATE ? March 2011 Tel: 020 8337 9609Page 3

·Drug induced Liver disease - Drugs and 45% respectively. Genetic commonly associated with liver counselling should be offered.abnormalities during pregnancy include,erythromycin, f lucloxacil l in, co- ·HELLP syndrome – H - haemolysis, amoxiclav, propylthiouracil , and EL - elevated LFT's, LP - low platelets. chlorpromazine. Reference to the 'BNF' This is a serious complication of pre-is recommended. eclampsia presenting as a combined

liver and clotting disorder. Incidence is ·Budd Chiari - Budd-Chiari syndrome 1:1000 pregnancies. It occurs in second,

is uncommon, occurring when hepatic third trimester and post partum. venous outflow is obstructed. Clinical Seizures can also occur. The definitive features include abdominal pain, treatment is prompt/early delivery. jaundice, ascites and encephalopathy. Maternal and perinatal mortality is 7-LFT's reveal raised AST/ALT. Liver 35% and 40% respectively. Recurrence transplantation maybe indicated. in subsequent pregnancies is 5%.

·Ruptured Liver – Occurs in the third trimester in older, multigravida mothers, pre-eclampsia, and in those with pre-existing lesions (eg. adenomas, cysts and These are conditions that are unique to and ·Pre-eclampsia - Pre-eclampsia may h e m a n g i o m a s ) . I n c i d e n c e o f induced by pregnancy. occur pre- (20 weeks or earlier) or spontaneous hepatic rupture is 1:

post-partum, affecting both mother and 45,000-225,000 deliveries. Maternal ·Hyperemesis gravidarum (HG) – foetus. Incidence is 5-10% but is mortality is high (18% to 86%). This is the most severe form of illness commoner in those with pre-existing within the spectrum of nausea and hypertension, diabetes, autoimmune vomiting of pregnancy. Incidence varies diseases, inherited thrombophilias, renal from 0.3 to 1% of pregnancies. It is disease, women with a family history of

?Abnormal liver function in pregnancy commoner in young, obese, multiparous pre-eclampsia, obese women, and in may run a benign course or may result in pregnancies. The nausea and vomiting women with a multiple gestation. One significant morbidity and mortality. characteristically presents at 4-10 third have abnormal LFTs. Regular foetal

?Diagnosis is made based on the weeks terminating by the week 20. scanning, control of hypertension are symptoms, the time of gestation, the Treatment is supportive. essential and planned delivery should be pattern of LFTs and the results of done as soon as the foetus is matureimaging. ·Intrahepatic cholestasis of

?Patients require regular monitoring and pregnancy (ICP) - or obstetric ·Acute Fatty Liver of pregnancy advice.cholestasis is associated with an (AFLP) – Occurrs in second, third

?Advice should be sought from a increased foetal risk of prematurity and trimester or post-partum. Incidence is Hepatologist and Obstetrician at the perinatal death. In the UK ICP affects 1:10000-15000 pregnancies. An earliest opportunity.0.5-0.7% of all pregnancies. Presents in autosomal recessively inherited

the third trimester. Risk factors include, disorder of fatty acid metabolism in the advanced age, multiple gestations, the long-chain 3-hydroxyacyl-coenzyme a oral contraceptive pill and a positive dehydrogenase enzyme present within family history. Symptoms include the mitochondria of the foetus. pruritis with jaundice developing in up Treatment is supportive requiring to 20%. Elevated transaminases and bile p ro m p t / e a r l y d e l i ve r y. L i ve r acids are common. Treatment requires transplantation may be indicated. Ursodeoyxcholic acid. Maternal and foetal mortality are 10%

Liver diseases specific to pregnancy

Summary

Dr Tony Rahman MA, DIC, PhD, BM, BCh, FRCP

Probiotics, which means "for life", have been who in the beginning of the 20th century Dysbiosis is the name given to the process used for centuries as natural components in suggested that it would be possible to by which an imbalance of gut microbes health-promoting foods. Probiotics are modify the gut flora and to replace harmful causes disease. This process has been dietary supplements containing potentially microbes by useful microbes. Metchnikoff implicated in irritable bowel syndrome, beneficial bacteria or yeasts. Medically, we suggested that this could have beneficial inflammatory bowel disease, antibiotic define probiotics as live microorganisms health effects. associated diarrhoea (including C. difficile which when administered in adequate diarrhoea) and pouchitis. amounts confer a health benefit on the In health there are more than 500 species of host. bacteria in gut microflora, these have a Scientific studies

symbiotic relationship with the host and The original observation of the positive role these bacteria are usually harmless and help There is an increasing body of scientific played by certain bacteria was first to stop disease-causing bacteria becoming evidence that probiotics have a place in the introduced to medicine by the Russian established. treatment of specific subtypes of irritable scientist and Nobel laureate Eli Metchnikoff,

Probiotics – Placebo or Panacea?

Continued overleaf...

LGP UPDATE ? March 2011 Tel: 020 8337 9609

bowel syndrome, pouchitis, antibiotic syndrome guidelines state that a trial of associated diarrhoea and inflammatory probiotics could be used for 4 weeks.

Unfortunately the guidelines do not specify which IBS subgroups would be most likely to benefit, or which probiotic preparation has an evidence base behind it.

Placebo or Panacea?

Many different preparations are available and some of these have been studied in formal medical trials to assess their clinical effectiveness and safety. There is good medical evidence that certain probiotics

Probiotics have an evolving position in can be used very effectively to treat specific gastroenterology – at present they should gastrointestinal problems (ranging from be considered as more than placebo but specific IBS subtypes, inflammatory bowel they fall short of being a panacea!disease, infectious diarrhoea and post bowel disease. However, putting this

colonic surgery syndromes). evidence into practice is more complex as many studies look at heterogeneous

From the scientific studies carried out to populations, most studies have used date it is clear that the effects of one different probiotic preparations and not all probiotic cannot be implied to be the same of these are presently available from reliable as another. While these studies have shown sources in England.probiotics to be very safe there are rare instances of probiotics being harmful and if Probiotics in primary carein doubt a specialist with knowledge of probiotics could advise about their use.The N.I.C.E. primary care irritable bowel

The London Gastroenterology Partners Clockwise from far left:

Dr Chris Groves Dr Daniel Forton BSc, MD, MBBS, FRCPBSc, PhD, MBBS, FRCP

Dr Jin-Yong Kang Dr Sarah Clark MD PhD FRCP, FRCPEd, FRACP BMedSci, MD, MBBS, FRCP

Dr Andy Poullis Dr Penny Neild BSc, MD, MBBS, FRCP Bsc, MD, MB, ChB, FRCP

Dr Tony Rahman MA, DIC, PhD, BM, BCh, FRCP

Head OfficeTel: 020 8337 9609Fax: 020 8668 7552Email: enquiries@londongastro.co.uk

The office is open between 8.30am and 5pm Monday to Friday.

With several clinics running everyday, patients should contact the office to arrange the most convenient appointment.

Secretaries are:

For Dr Neild, Dr Groves or Dr Clark speak to JanFor Dr Poullis or Dr Rahman speak to NatalieFor Dr Forton speak to SarahFor Dr Kang speak to Susan on 020 8339 9474

To make Dietetic referrals and appointments please speak to Sarah or Natalie.

If you are uncertain which Consultant would best suit your patients, please call the office for advice.

Dr Andy Poullis BSc, MD, MBBS, FRCP

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Foe: Clostridium difficile

Friend: Bifidobacterium infantis

Rapid Referral RouteEmail: referrals@londongastro.co.uk to ensure your patients’ details reach us and appointments are offered quickly. We can always see patients within 24 hours of a referral.