Updates in Gastroenterology

Kally Alexandropoulou MBBChir MA MRCPConsultant Gastroenterologist

Topics to cover

• GORD and oesophageal physiology - NICE guidelines 2014HRM/ pH impedance

• Barrett’s - BSG guidelines 2012, 2013• Eosinophilic oesophagitis - ACG guidelines 2013• Coeliac disease – BSG guidelines 2014• IBD - BSG guidelines 2010, 2011, 2012• IDA - BSG guidelines 2011• Bowel preparation - BSG guidelines 2012

• Hepatology: Early access programme for directly acting antiviral drugs (DAAs)

- protease inhibitors ; nucleotide polymerase inhibitors

DyspepsiaSwitch from PUD to GORD

• PUD – gastric and duodenal ulceration• Still high risk mortality in elderly • Falling rates due to reduction in prevalence of helicobacter pylori

• HP prevalence reduction due to - improving socio-economic conditions- exposure to antibiotics and PPIs- Eradication policies via dyspepsia guidelines with ‘test and treat’.

GORD• Increasing prevalence, affecting up to 25% in USA and Europe

El-Serag, GUT 2014

• Increased BMI• Increasing prevalence of hiatus hernia • H pylori eradication• Older population: polypharmacy (IHD/COPD)

• Reflected increases in BO and oesophageal adenocarcinoma• OAC has overtaken squamous oesophageal cancer in incidence• OAC is the 9th commonest malignancy in UK, and has poor prognosis• UK has the highest incidence of OAC in Europe • OAC is rapidly increasing in incidence, with rates increased from 7.6 to

12.8 /100 000 men between 1971 and 1999 in England and Wales

Alim Pharm Ther.2003; 17(5):655-64

SymptomsHeartburnEpigastric pain/atypical chest painNausea and vomitingDysphagia

Laryngo-pharyngeal refluxSore throat, post nasal drip, early morning nausea, breathlessness/ ‘asthma’

10-15% patients with PPI refractory symptoms

Severity of symptoms do not necessarily correlate with endoscopic findings; endoscopy and pH manometry studies help distinguish between

• Erosive reflux• Non erosive reflux• Weakly acidic and non acid reflux – impedance testing• Hypersensitive oesophagus/ Functional heartburn

Endoscopic findings• Erosive reflux

LA classification

• Ulceration• Strictures• Barrett’s

• Malignancy

• Normal ?Non erosive reflux ?Eosinophilic oesophagitis

Oesophageal physiologyOesophageal manometry and 24 hour pH impedance study

• Oesophageal manometry: initially pull through water perfused 8 sensor catheters with 4 longitudinal sensors, 5 cm apart, assessing body activity and 4 radial sensors assessing lower oesophageal body activity;

• Cumbersome and limited information

Now:• High Resolution Manometry (HRM) catheters with digital 36 point

pressure sensors, 1 cm apart• Enables simultaneous monitoring of motility from the pharynx to the

stomach• Can be combined with impedance to assess function by observing bolus

clearance: evolution in oesophageal function assessment

High resolution manometry• High-resolution manometry

(HRM):pressure sensors spaced at 1cm intervals, so simultaneous monitoring of motility from the pharynx to the stomach

• Indications:-evaluate peristalsis and LOSfor GORD severity and prior to fundoplication- dysphagia: achalasia, spastic disorders-non cardiac chest pain

24 hour pH study

Trans-nasally inserted pH catheter with 2 sensors at distal end of the catheter, 15cm apart: lower sensor at the tip of the catheter measures gastric pH while upper sensor is positioned 5 cm above the proximal edge of the LOS and measures oesophageal acid exposure.

Impedance testing

• Impedance measures resistance to current flow • Impedance changes across the oesophagus during passage of

air, liquid, food and refluxate

• It identifies direction of bolus movement and clearance in the oesophagus

• Combined with HRM to assess bolus clearance and • 24 hour pH testing to identify acid and non acid reflux events

- more insight into ‘PPI refractory reflux’ aetiology

HRM - impedance

HRM – with impedance HRM – weak oesophageal dysmotility

Combined pH and Impedance

‘Mass’ symptoms with partial response to PPIs; OGD: large hiatus hernia; assessment for fundoplication

Impedance testing• Comparing recordings of the same individuals with PPI refractory GORD on

and off PPIs, there is a striking decrease in acid reflux events, but a corresponding increase in weakly acidic reflux events and heartburn was replaced by regurgitation as the dominant symptom.

• Impedance–pH monitoring studies in patients with PPI-refractory GORD symptoms suggest that:- acid reflux was associated with 7%–28% of persistent symptoms, - weakly acidic reflux with 30%–40% of symptoms, and - 30%–60% of symptoms were not preceded by any reflux – functional heartburn

NB Hypersensitive oesophagus – reflux symptoms correlating with reflux episodes in presence of non pathological acid reflux

TreatmentImportance of offering optimised PPI treatment: • Full-dose PPI for 1 or 2 months.

- Extending treatment to 2 months increased healing of oesophagitis by a further 14%. - If patients have severe oesophagitis and remain symptomatic, double-dose PPI for a further month may increase the healing rate.

NB Surgical fundoplication

• Non erosive reflux disease still responds to PPIs – prn basis may be sufficient• Non acid reflux and functional reflux may still respond to PPI treatment; trial

of prokinetics and/or H2RA should also be considered

Barrett’s Oesophagus, BOPrevalence rate for BO at 1.3% in the general population

There is 30 –fold increased risk of development of oesophageal adenocarcinoma (OAC) in BO

Progression occurs through step wise change to low (LGD) and high grade dysplasia (HGD)

Risk factors for development of Barrett’s:• White males, >50yrs• GORD >10yrs, Hiatus hernia, BMI >30• Smoking

Risk factors for progression to OAC:• Intestinal metaplasia, dysplasia: HGD vs LGD• Length of BO >6cm, BO >10yrs• Oesophagitis, GORD esp night-time

Barrett’s surveillanceUpdated guidelines• Reporting using the Prague

criteria: circumferential extent (C), maximum extent (M) of columnar epithelium

• Access to clinic to discuss diagnosis and pros/cons of surveillance

• Surveillance to take into account risk factors, pt fitness and pt preference

• IM and length of Barrett’s to inform surveillance regimen

Consensus in Mx of HGD

GASTROENTEROLOGY 2012GUT 2012

Endoscopic Mucosal Resection, EMR

• Inject saline to raise lesion off submucosa to reduce risk of transmural thermal injury during snaring

• Use polypectomy snare to resect and cauterise lesion

• Lesion retrieved for histology

Endoscopic mucosal resection

Staging of invasive lesionsCurative resection of superficial lesions

Invasive, risk of strictures and perforation

Effective in expert hands, high volume centres

Combination with RFA for elimination of Barrett’s metaplasia in patients with HGD/LGD

Radiofrequency ablation, RFA

Thermal ablation of non-dysplastic and dysplastic Barrett’s mucosa to 1mm depth with bursts of heat via 360 degrees coil of radiofrequency electrodes, Fitted over a balloon andapplied circumferentially or smaller 90 degrees

catheter

Radiofrequency Ablation, RFAMeta-analysis 24 studies, with >4000 pts with Barrett’s and

dysplasia (LGD or HGD)/IM treated with RFAWith follow up between 12 and 31 months, following 2-3

sessions of RFA:91% complete tx of neoplasia78% complete remission of IM13% recurrence of IM0.9% progressed to dysplasia and 0.7% to cancer after IM remission, at 1.5yrs5% developed strictures

Shaheen et al Clin Gastro Hep 2013; 11(10):p1245–1255

Eosinophilic OesophagitisClinical and histologic information required for diagnosis:• Symptoms related to oesophageal dysfunction: dysphagia, food bolus

obstruction, retrosternal pain/ heartburn• ≥15 eos/hpf in at least 1 oesophageal biopsy specimen, with few

exceptions• Eosinophilia limited to the oesophagus• Other causes of esophageal eosinophilia need be excluded, particularly

GORD and PPI-related oesophageal eosinophilia (PPI-REE)ACG guidelines 2013

• Affects children and adult (mainly) men aged 20-40 yrs with history of atopy

• Responds to swallowed steroid inhalers: fluticasone; viscous budesonide.• Elimination diets are effective in children, encouraging new data in adults

for dietary therapy

Diagnosis and Management algorithm for

EoE

Clin Gastro&Hep 2012

Coeliac disease• Immune mediated small intestinal enteropathy• Triggered by dietary gluten (NB oats OK)• Prevalence 1%• Strong genetic component: HLA DQ2/8, 10% prevalence in 1st degree

relatives• Diagnosis by serology AND duodenal biopsy• 6-22% seronegative CD• Follow up: better adherence to gluten free diet if in specialist clinic 97/5%

vs 40.4%• Follow up D2 biopsies: at 1 yr if still symptomatic or positive serology• Baseline Ca/vit D levels and supplementation if needed + DEXA scan• Pneumovaccine if hypospenism• Screen for CD in IDA/Down’s/DM type1/Osteoporosis/IBS

Refractory coeliac disease

Persistent or recurrent malabsorptive symptoms and/or villous atrophy despite gluten free diet for >12 months (in absence of other causes); Incidence ~1%

• RCD type I: may respond to oral steroids/ immunosuppresants

• RCD type II: monoclonal/ abberant T lymphocytes poor prognosis: nutritional compromise and increased risk of enteropathy associated T cell lymphoma (EATL)EATL 5 year survival <20%RCD type II tx limited, include cyclosporine and high dose chemotherapy + autologous stem cell support

Inflammatory Bowel DiseaseInduction of remission:- Glucocorticoids: pred 40mg reduce by 5mg weekly (bone protection)- Budesonide (9mg od) may be effective in ileal/ R colonic disease- 5- ASA high dose, in moderate UC- 5- ASA may have a role in colonic Crohn’s- Cyclosporin vs Infliximab for acute colitis

Maintenance of remission:- Steroids should not be offered routinely- 5- ASA in UC, once daily dosing, reduce CRC risk (by as much as 75%)- 5- ASA in Crohn’s colitis (?)- Azathioprine/ 6 mercaptopurine – check TPMT; 6TGN/6MeMP- Methotrexate- Anti TNF: Infliximab/ Adalimumab (certolizumab, golimumab)

IBD – Quality Care Service standards• Published in 2009; National IBD audits 2006, 2008, 2011, 2014• Hospital IBD service aims to comply with set standards

- IBD team: IBD nurse, surgeons with IBD interest, dietetic input- Local delivery of care: arrangements for shared care- Patient centred care: patient choice, rapid access to care- Patient education and support- Audit and research: IBD patient databases

Latest Audit 2014:• Variable care for UC patients across UK with >40% receiving substandard or

delayed initial standard treatment, not seeing pts with relapse in ≤7 d• Need for accurate assessment of disease activity• Nutritional assessment upon admission• Anaemia to be actively investigated and treated• Limited access to psychological supportDoing better in Bone protection

VTE prevention and screening for C diff infection

IBD

Faecal Calprotectin: screening and disease activity monitoring

ECCO guidelines 2009 against opportunistic infections• Screen for HBV/VZV and vaccinate if negative• HPV vaccination as per national guidelines

Locally• IBD nurse specialist – telephone and email access• IBD dietitian – ward based and parallel clinics with gastro• Patient group• Surrey IBD group

Iron deficiency anaemia

• Ferritin (check ESR/CRP) to confirm IDA• Upper AND lower GI investigations (unless advanced gastric

neoplasia found) advised: dual pathology in up to 10% cases• Coeliac screening in all• Urine testing for blood mandatory in all• FOBs of no benefit in IDA

• Iron deficiency with no anaemia, consider investigations in post menopausal women and men >50yrsGUT 2011

Bowel preparation for colonoscopy

• BSG guidance in response to National PatientSafety Agency report in 2009 on the potential risks of bowel cleansing agents (BSG guidance 2012)

• clinical assessment of each patient for contraindications and risks required,

• the use and choice of a bowel-cleansing preparation is authorised by a clinician, and

• an explanation on its use is provided to the patient• Guidance is for clinicians prescribing these agents and for

those referring for procedures that require them

Cleansing agents

• Moviprep/kleanprep – iso- osmotic and non absorbable, less fluid and electrolyte shifts

• Fleet, Citrafleet, picolax, citramag – hyper- osmotic: draw large volume of water into colon SO considered 2nd line agents in presence of comorbidities including CKD, CCF, liver disease

• Complications include: hypovolaemia, hypokalaemia, hyponatraemia, phosphate nephropathy

Prescribing bowel preparation

• Check U&Es, eGFR and co-morbidities to inform choice of cleansing agent

• Diuretics, ACEi/ARA, NSAIDs to be omitted for 72 hrs

• Absorption of medication affected eg OCP• In diabetics, insulin and oral anti-glycaemic medication needs

to be reduced

• Oral iron discontinued 5 days before• Anticoagulants and clopidogrel may need to be discontinued

Summary pointsGORD• Optimise PPI use in GORD (?EoE)• HRM and Impedance testing for PPI refractory GORD Barrett’s• No surveillance for short segment BO with no intestinal metaplasia • Endoscopic treatment advised for HGD/ in situ cancer in BOIBD• Once daily 5-ASA for UC• Bone protection while on steroid treatment mandatory• Screen and vaccinate for HBV/VZV prior to immunosuppressant Tx• Risk stratification guiding surveillance colonoscopiesIDA• Coeliac serology, urinalysis in all• Iron deficiency with no anaemia investigations in >50yr men and post menopausal womenBowel cleansing agents• Careful assessment of patients referred for colonoscopy needed

QUESTIONS?