Pali Hungin

Guidelines on the irritable bowel syndrome: mechanisms and practical management

Background: IBS affects 5–11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance. Aim: To provide a guide for the assessment and management of adult patients with irritable bowel syndrome. Methods: Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases. Results: Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients’ concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT3 antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT4 agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms. Conclusions: Better ways of identifying which patients will respond to specific treatments are urgently needed.

British Society of Gastroenterology guidelines for the management of the irritable bowel syndrome.

### 1.1 PURPOSE OF GUIDELINES These guidelines were compiled by a multidisciplinary group at the request of the chairman of the British Society of Gastroenterologys Clinical Services Committee. The prime targets for these guidelines are consultant gastroenterologists, specialist registrars in training, and general practitioners. The purpose is to identify and inform the key decisions to be made in the management of patients thought to have functional diseases of the gut. As these comprise the commonest conditions seen by gastroenterologists, the working party represented a wide spectrum of practitioners in gastroenterology, including gastroenterologists from both district general hospitals and tertiary referral centres, as well as primary care practitioners, psychiatrists, psychologists, and dietitians. ### 1.2 SPECIFIC DIFFICULTIES Compared with producing guidelines for the management of well defined diseases such as peptic ulcer where there is a clear disease entity, an obvious end point, and highly effective treatments, drawing up guidelines for functional gastroenterological disorders has had many difficulties. Clinical trials have been difficult to design as the conditions being treated are highly variable with many possible end points, and most therapies only marginally more effective than placebo. Early trials were difficult to evaluate because of inadequate patient definition so that many questions have yet to be addressed with good quality randomised controlled clinical trials. Most of our recommendations are therefore supported by clinical experience rather than randomised controlled clinical trials. Finally, because functional diseases, although potentially debilitating, are non-fatal there are few uniformly available audit measures such as mortality or survival times by which to judge or compare different treatment regimens in different areas of clinical practice. ### 1.3 PROCESS OF GUIDELINE CREATION The co-chairmen were approached by the chairman of the British Society of Gastroenterologys Clinical Services Committee and invited to form a working party. Members were chosen to be broadly representative of clinicians and academics with a long term interest and publication record in the …

Is the two week rule for cancer referrals working?: Not too well

Mortality rates in the United Kingdom for several cancers compare unfavourably with those in other countries,1 and this may be explained at least partly by British patients having more advanced disease at the time of treatment than their European counterparts. Morbidity and mortality can be reduced through primary and secondary prevention, including screening; by early detection; and by prompt and effective treatment. Last year, in the context of the NHSs disgracefully long waiting lists, the government pledged that patients with suspected cancer would be seen by a specialist within two weeks of referral by their general practitioner. The aim was to reduce delays between presentation, diagnosis, and treatment. The two week rule has now been implemented across a range of specialties, supported by widely distributed information about risk factors and criteria for rapid referral for suspected cancer. How is it working? Local rapid access referral mechanisms have been established, including specially designed forms and direct electronic access to outpatient appointments for patients meeting prespecified criteria. In addition, the government established the cancer services collaborative programme, creating nine cancer networks covering about 15 million people, aimed at optimising systems of care and improving …

The management of common gastrointestinal disorders in general practice A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries.

BACKGROUND Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. AIM AND METHODS We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. RESULTS We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. CONCLUSION The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Nutritional aspects of epigenetic inheritance

The impact of diet and environmental factors on genes concerned with epigenetic inheritance and the mechanism of evolution has grown significantly beyond the Modern Synthesis period. Epigenetic inheritance is the passing of phenotypic change to subsequent generations in ways that are outside the genetic code of DNA. Recently, polymorphisms of the human Delta-5 (fatty acid desaturase, FADS1) and Delta-6 (FADS2) desaturase genes have been described as being associated with the level of several long-chain n-3 and n-6 polyunsaturated fatty acids (PUFAs) in serum phospholipids. Increased consumption of refined starches and sugar increases the generation of superoxide anion in the tissues and free fatty acids (FFA) in the blood. There is an increased amount and activity of nuclear factor-κB (NF-κB), a transcriptional factor regulating the activity of at least 125 genes, most of which are pro-inflammatory. The consumption of glucose may be associated with an increase in 2 other pro-inflammatory transcription factors: activating protein-1 (AP-1), and early growth response protein-1 (Egr-1). AP-1 regulates the transcription of matrix metallo-proteinases and Egr-1 modulates the transcription of tissue factor and plasminogen activator inhibitor-1. It is possible that a complex set of factors, including nutritional factors, come into play during epigenetic inheritance.

Coping with common gastrointestinal symptoms in the community: a global perspective on heartburn, constipation, bloating, and abdominal pain/discomfort May 2013.

Review Team: Richard Hunt, MD (Co-chair, Canada/UK), Eamonn Quigley, MD (Co-chair, USA), Zaigham Abbas, MD (Pakistan), Abraham Eliakim, MD (Israel), Anton Emmanuel, MD (UK), Khean-Lee Goh, MD (Malaysia), Francisco Guarner, MD (Spain), Peter Katelaris, MD (Australia), Andre Smout, MD (Netherlands), Mohammad Umar, MD (Pakistan), Peter Whorwell, MD (UK), John Johanson, MD (USA), Roque Saenz, MD (Chile), Luc Besançon, (France), Edith Ndjeuda, Pharm D (France), John Horn, Pharm D, FCCP (USA), Pali Hungin, MD (UK), Roger Jones, MD (UK), Justus Krabshuis, (France), and Anton LeMair, MD (Netherlands)

The impact of IBS on absenteeism and work productivity: United States and eight European countries

The impact of IBS on absenteeism and work productivity: United States and eight European countries

Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition

Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.

Improving the quality of colonoscopy

1. Blomberg J, Lagergren P, Martin L, et al. Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study. Gastrointest Endosc 2011;73: 29-36. 2. McMillan DC, Crozier JE, Canna K, et al. Evaluation of an inflammationbased prognostic score (GPS) in patients undergoing resection for colon and rectal cancer. Int J Colorectal Dis 2007;22:881-6. 3. Forrest LM, McMillan DC, McArdle CS, et al. Evaluation of cumulative prognostic scores based on the systemic inflammatory response in patients with inoperable non-small-cell lung cancer. Br J Cancer 2003;89: 1028-30. 4. McMillan DC. An inflammation-based prognostic score and its role in the nutrition-based management of patients with cancer. Proc Nutr Soc 2008;67:257-62. 5. Moyes LH, Leitch EF, McKee RF, et al. Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer. Br J Cancer 2009;100:1236-9. 6. Ishizuka M, Nagata H, Takagi K, et al. Influence of inflammation-based prognostic score on mortality of patients undergoing chemotherapy for far advanced or recurrent unresectable colorectal cancer. Ann Surg 2009; 250:268-72. 7. Pfitzner T, Krocker D, Perka C, et al. C-reactive protein. an independent risk factor for the development of infection after primary arthroplasty [German]. Orthopade 2008;37:1116-20. doi:10.1016/j.gie.2011.09.035

Colonoscopic perforations in the English National Health Service Bowel Cancer Screening Programme

BACKGROUND Perforation is the most serious adverse event associated with colonoscopy. In this study of data from the English National Health Service Bowel Cancer Screening Programme, we aimed to describe the presentation and management of perforations, and to determine factors associated with poorer outcomes post-perforation. METHODS The medical records of patients with a perforation following the national screening colonoscopy were retrospectively examined. All colonoscopies performed from 02/08/2006 to 13/03/2014 were studied. Bowel Cancer Screening Centres across England were contacted and asked to complete a detailed dataset relating to perforation presentation, management, and outcome. RESULTS 263 129 colonoscopies were analyzed, and the rate of perforation was 0.06 %. Complete data were reviewed for 117 perforations: 70.1 % of perforations (82/117) occurred during therapeutic colonoscopies; 54.9 % (62/113) of patients with perforations who were admitted to hospital and in whom data were complete underwent surgery; 26.1 % (30/115) of hospitalized patients left the hospital with a stoma and 19.1 % (22/115) developed post-perforation morbidity. Perforations not detected during colonoscopy were significantly more likely to require surgery (P = 0.03). Diagnostic perforations were significantly more likely to require surgery (P = 0.002) and were associated with higher rates of post-perforation morbidity (P = 0.01). At presentation, the presence of abdominal pain (P = 0.01), a pulse rate > 100 beats per minute (P = 0.049), and a respiratory rate > 20 breaths per minute (P = 0.01) were significantly associated with the patient having surgery. CONCLUSIONS This is the largest retrospective observational case series in Europe to describe post-perforation presentation, management, and outcomes. We have confirmed that perforation leads to surgical intervention, stoma formation, and post-perforation morbidity. Perforations not recognized during the colonoscopy were significantly more likely to require surgery. Diagnostic perforations were at greater risk of requiring surgery and developing post-perforation morbidity.