Joel Mawdsley

The Role of Psychological Stress in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is an idiopathic inflammatory condition of the gastrointestinal tract whose natural history is one of periods of remission and relapse. The aetiology is complex and reflects an interaction between genes and environment. Psychological stress has long been reported by both doctors and patients as worsening disease activity in IBD. Prospective studies of the relationship between disease relapse and adverse life events have produced conflicting results, in part due to the inherent difficulties of such studies. However, several more recent analyses have suggested that both adverse life events and chronic perceived stress can contribute to disease relapse. There is also an increasing body of evidence to suggest that experimental stress can increase mucosal inflammation both in patients with IBD and in animal models of colitis. Despite this increase in understanding the pro-inflammatory effects of stress in IBD, thus far only a few limited studies have examined stress reduction as a therapeutic modality.

The Effect of Hypnosis on Systemic and Rectal Mucosal Measures of Inflammation in Ulcerative Colitis

OBJECTIVES:Hypnotherapy is effective in several diseases with a psychosomatic component. Our aim was to study the effects of one session of hypnosis on the systemic and rectal mucosal inflammatory responses in patients with active ulcerative colitis (UC).METHODS:In total, 17 patients with active UC underwent a 50-min session of gut-focused hypnotherapy. Before and after each procedure, the systemic inflammatory response was assessed by serum interleukin (IL)-6 and IL-13 concentrations, tumor necrosis factor-alpha (TNF-α) and IL-6 production by lipopolysaccharide (LPS)-stimulated whole blood, leukocyte count, natural killer (NK) cell number, platelet activation, and platelet–leukocyte aggregate formation. Rectal inflammation was assessed by mucosal release of substance P (SP), histamine, IL-13 and TNF-α, reactive oxygen metabolite production, and mucosal blood flow. Eight patients with active UC underwent a control procedure.RESULTS:Hypnosis decreased pulse by a median 7 beats per minute (bpm) (P= 0.0008); it also reduced the median serum IL-6 concentration by 53% (P= 0.001), but had no effect on the other systemic variables assessed. Hypnosis reduced rectal mucosal release of SP by a median 81% (P= 0.001), histamine by 35% (P= 0.002) and IL-13 by 53% (P= 0.003), and also, blood flow by 18% (P= 0.0004). The control protocol had no effect on any of the variables assessed.CONCLUSIONS:Hypnosis reduced several components of the systemic and mucosal inflammatory response in active ulcerative colitis toward levels found previously in the inactive disease. Some of these effects may contribute to the anecdotally reported benefits of hypnotherapy and provide a rationale for controlled trials of hypnotherapy in UC.

Optimizing quality of outpatient care for patients with inflammatory bowel disease : the importance of specialist clinics

Background Most patients with inflammatory bowel disease (IBD) undergo long-term outpatient follow up. However, quality of care provided by specialist and non-specialist IBD clinics is rarely critically audited. Objective To compare the standard of outpatient care provided by general gastroenterology and specialist IBD clinics within a single hospital using defined quality criteria. Methods The case notes of 60 consecutive patients with IBD attending general gastroenterology clinics and of 100 patients attending the specialist IBD clinic were reviewed for fulfilment of six quality criteria over the preceding 18 months. Results The proportion of patients fulfilling all six criteria was higher in the specialist IBD clinic. In the specialist IBD clinic, compared with the general gastroenterology clinics, blood tests were performed with appropriate frequency during the initiation of immunosuppressive treatment in 7/11 versus 2/12 patients (P=0.04) and during maintenance in 24/31 versus 6/21 patients (P=0.001); bone protection with oral steroids were given to 25/53 versus 4/24 patients (P=0.01); a screening colonoscopy at 8–10 years was performed in 25/27 versus 11/20 patients with ulcerative colitis (P=0.004); annual serum urea and creatinine concentrations were measured in 82/89 versus 31/45 patients prescribed 5-aminosalicylates (P=0.001); annual liver function tests were performed in 96/100 versus 38/60 patients (P=0.001); and annual haematinics were measured in 37/47 versus 18/33 patients with Crohns disease (P=0.03). Conclusion By these criteria, the specialist IBD clinic provided better care than the non-specialist general gastroenterology clinics. Even in the specialist clinic, however, the care of a minority of patients did not fulfil certain criteria, emphasizing the need for a critical audit of outpatient management of IBD.

IgG antibodies to foods in IBS

Haemochromatosis is a common inherited disorder of iron metabolism, characterised by excessive iron absorption and deposition in tissues. The majority of cases are associated with mutations in the HFE gene and inherited in an autosomal recessive manner.1 Autosomal dominant forms of haemochromatosis have been reported, mainly associated with mutations in the ferroportin 1 gene.2 This syndrome, termed type 4 haemochromatosis or more recently ferroportin disease,3 is usually characterised by an early increase in serum ferritin with normal transferrin saturation. Iron accumulation is most prominent in Kupffer cells and other macrophages, in addition to hepatocytes. Some patients do not tolerate venesection therapy well and can develop anaemia. Hereditary iron overload disorders appear to be uncommon in Asia. Secondary iron overload due to beta thalassaemia is relatively common in the Indian subcontinent. However, primary iron overload disorders …