to the ileum ……. and beyond dr. matt w. johnson bsc mbbs mrcp (??md!!) consultant...

To the ileum …….To the ileum …….and beyondand beyond

Dr. Matt W. Johnson Dr. Matt W. Johnson BSc MBBS MRCP (??BSc MBBS MRCP (??MD!!)MD!!)

Consultant GastroenterologistConsultant Gastroenterologist

1909 Royal Military Asylum1909 Royal Military Asylum

1733 – Hyde Park1733 – Hyde Park

1976 - Tooting1976 - Tooting

St. George’s HospitalSt. George’s Hospital

AchievementsAchievements

• First Class BSc Degree First Class BSc Degree • Medical Sciences with PhysiologyMedical Sciences with Physiology

• Physiology research project: Effects of alpha and beta Physiology research project: Effects of alpha and beta sympathetic adrenoreceptors on mucus content and quantity.sympathetic adrenoreceptors on mucus content and quantity.

• MBBS MBBS (University of London)(University of London)

• Eating in every one of the 28 Indian Eating in every one of the 28 Indian restaurants from Tooting Broadway to Tooting restaurants from Tooting Broadway to Tooting BecBec

HO + SHO PostsHO + SHO Posts

MEDICAL SHO POSTSMEDICAL SHO POSTS• St. Helier Hospital,St. Helier Hospital, Gastro and GIM Gastro and GIM • Hemel Hempstead Hospital,Hemel Hempstead Hospital, Gastro, Haem and GIMGastro, Haem and GIM• Royal Free Hospital, Royal Free Hospital, Specialist Liver Unit and GIMSpecialist Liver Unit and GIM • St. Thomas’ Hospital,St. Thomas’ Hospital, CardiologyCardiology• Lewisham Hospital,Lewisham Hospital, Endocrine and GIMEndocrine and GIM• Lewisham Hospital,Lewisham Hospital, Care of the Elderly Care of the Elderly • Guy’s Hospital,Guy’s Hospital, Accident and Emergency Accident and Emergency

PRE REGISTRATION HOUSE OFFICERPRE REGISTRATION HOUSE OFFICER• Mayday Hospital,Mayday Hospital, General Surgery and ENTGeneral Surgery and ENT• St. George’s Hospital,St. George’s Hospital, GIM and Care of the ElderlyGIM and Care of the Elderly

St. Thomas’s HospitalSt. Thomas’s Hospital

South East Thames SpR South East Thames SpR Rotation Rotation QUEEN ELIZABETH THE QUEEN MOTHER (MARGATE) HOSPITALQUEEN ELIZABETH THE QUEEN MOTHER (MARGATE) HOSPITAL • Dr. A. Piotrowicz, Dr. K. Hills Dr. A. Piotrowicz, Dr. K. Hills DARENT VALLEY HOSPITALDARENT VALLEY HOSPITAL • Dr. W. Melia, Dr. R. Ede, Dr. P. Mairs Dr. W. Melia, Dr. R. Ede, Dr. P. Mairs KINGS COLLEGE HOSPITAL - LIVER UNITKINGS COLLEGE HOSPITAL - LIVER UNIT

General Hepatopancreatobiliary / Liver ITU / Transplant MedicineGeneral Hepatopancreatobiliary / Liver ITU / Transplant Medicine• Dr. J. O’Grady, Dr. M. Heneghan, Dr. J. Devlin, Dr. P. Harrison, Dr. J. O’Grady, Dr. M. Heneghan, Dr. J. Devlin, Dr. P. Harrison, • Dr. V. Aluvihare, Dr. K. Agarwal, Dr. E. Sizer, Dr. W. Bernal. Dr. V. Aluvihare, Dr. K. Agarwal, Dr. E. Sizer, Dr. W. Bernal. • Dr. G. Auzinger, Dr. J. Wendon. Dr. G. Auzinger, Dr. J. Wendon. St. MARK’S and St. THOMAS’S HOSPITALSt. MARK’S and St. THOMAS’S HOSPITAL• Research Fellowship, Specialist Surgical GastroenterologyResearch Fellowship, Specialist Surgical Gastroenterology• Prof R.J. Nicholls, Prof P.J. Ciclitira and Prof A. ForbesProf R.J. Nicholls, Prof P.J. Ciclitira and Prof A. ForbesSt. THOMAS’ and GUYS’ NHS TRUSTSt. THOMAS’ and GUYS’ NHS TRUST• Sir R. Thompson, Prof P.J. Ciclitira, Dr. J. Meenan, Sir R. Thompson, Prof P.J. Ciclitira, Dr. J. Meenan, • Dr. J. Sanderson, Dr. T. Wong, Dr. M. Wilkinson, Dr. R.EdeDr. J. Sanderson, Dr. T. Wong, Dr. M. Wilkinson, Dr. R.EdeBROMLEY NHS TRUSTBROMLEY NHS TRUST• Dr. J. Hunt, Dr. A. Jenkins, Dr. M. AsanteDr. J. Hunt, Dr. A. Jenkins, Dr. M. AsanteROYAL SURREY COUNTY HOSPITALROYAL SURREY COUNTY HOSPITAL• Dr. M. SmithDr. M. Smith

FRIMLEY PARK HOSPITAL - LASFRIMLEY PARK HOSPITAL - LAS• Col. Fabricius, Col. InesonCol. Fabricius, Col. Ineson

Specialty Areas of Interest Specialty Areas of Interest

•Inflammatory Bowel DiseaseInflammatory Bowel Disease – including – including tertiary referral clinics at St. Mark’s and St. tertiary referral clinics at St. Mark’s and St. Thomas’s hospitals. Thomas’s hospitals.

•Surgical GastroenterologySurgical Gastroenterology - National Referral - National Referral Unit for ileoanal pouches, faecal incontinence, Unit for ileoanal pouches, faecal incontinence, complex anorectal fistula disease at St. Mark’scomplex anorectal fistula disease at St. Mark’s

•Small bowel pathology + Coeliac disease Small bowel pathology + Coeliac disease tertiary referral clinicstertiary referral clinics for complicated and for complicated and non-responsive cases.non-responsive cases.

•HepatologyHepatology (General hepatopancreatobiliary (General hepatopancreatobiliary medicine, Hepatitis clinics, Liver ITU, pre/post medicine, Hepatitis clinics, Liver ITU, pre/post liver transplant medicine)liver transplant medicine)

17 Publications17 Publications

20092009Coeliac disease in the elderly. Coeliac disease in the elderly. Nat Clin Pract Gastroenterol Hepatol. 2008 Dec; 5(12): 697-706Nat Clin Pract Gastroenterol Hepatol. 2008 Dec; 5(12): 697-706Bacterial community diversity in cultures derived from healthy and inflamed ileal pouches after restorative proctocolectomy. IBD. 2009 NovBacterial community diversity in cultures derived from healthy and inflamed ileal pouches after restorative proctocolectomy. IBD. 2009 NovThe bacteriology of pouchitis: A molecular phylogenetic analysis. GUT. 2009. DecThe bacteriology of pouchitis: A molecular phylogenetic analysis. GUT. 2009. DecThe prevalence of osteoporosis and osteopenia in ileal pouch patients post-restorative proctocolectomy. IBD. 2009. SeptThe prevalence of osteoporosis and osteopenia in ileal pouch patients post-restorative proctocolectomy. IBD. 2009. SeptProlonged toxic megacolon secondary to Salmonella. [Submitted to Diseases of the Colon and Rectum]Prolonged toxic megacolon secondary to Salmonella. [Submitted to Diseases of the Colon and Rectum]

20082008Coeliac disease in the older patient: Are we ageist in our practice.Coeliac disease in the older patient: Are we ageist in our practice. [Awaiting publication in [Awaiting publication in Gastroenterolgy CME Journal] Gastroenterolgy CME Journal] The medical management of patients with an ileal pouch anal anastomosis after restorative proctocolectomy. EJoGH. The medical management of patients with an ileal pouch anal anastomosis after restorative proctocolectomy. EJoGH. Faecal M2-pyruvate kinase; a novel, non-invasive marker of ileal pouch inflammation. EJoGHFaecal M2-pyruvate kinase; a novel, non-invasive marker of ileal pouch inflammation. EJoGH

2007 2007 Faecal calprotectin: A non-invasive diagnostic tool and marker of severity in pouchitis. Eur J Gastroentero Hepatol. 2008 March; 20(3): 174-179 Faecal calprotectin: A non-invasive diagnostic tool and marker of severity in pouchitis. Eur J Gastroentero Hepatol. 2008 March; 20(3): 174-179

20062006Hyperbaric oxygen as a treatment for malabsorption in a radiation damaged short bowel. June 2006; 18(6):685-688Hyperbaric oxygen as a treatment for malabsorption in a radiation damaged short bowel. June 2006; 18(6):685-688Risk of dysplasia and adenocarcinoma following restorative procto-colectomy for ulcerative colitis. Colorectal Disease. CDI-00256-2005.R1. 03/05/06 Risk of dysplasia and adenocarcinoma following restorative procto-colectomy for ulcerative colitis. Colorectal Disease. CDI-00256-2005.R1. 03/05/06

20052005Use of fecal lactoferrin to diagnose irritable pouch syndrome: A word of caution. Gastroenterology. 2004. 127(5):1647-8Use of fecal lactoferrin to diagnose irritable pouch syndrome: A word of caution. Gastroenterology. 2004. 127(5):1647-8Presentation, diagnosis and management of inflammatory bowel disease in older people. CME Geriatric Medicine, 2005; 7(3): 149-153Presentation, diagnosis and management of inflammatory bowel disease in older people. CME Geriatric Medicine, 2005; 7(3): 149-153The pathogenesis of coeliac disease. Molecular Aspects of Medicine, Dec 2005: 26 (6); 421-458The pathogenesis of coeliac disease. Molecular Aspects of Medicine, Dec 2005: 26 (6); 421-458

2004 2004 11th International Symposium on Coeliac Disease: A report. Gastroenterology Today. Summer 2004; 14 (2): 46-7 11th International Symposium on Coeliac Disease: A report. Gastroenterology Today. Summer 2004; 14 (2): 46-7 Clinical toxicity of HMW glutenin subunits of wheat to patients with celiac disease. Clinical toxicity of HMW glutenin subunits of wheat to patients with celiac disease.

Proceedings of the 19th Meeting of the Working Group on the prolamin analysis and toxicity, 2004; III Symposium: 147-9Proceedings of the 19th Meeting of the Working Group on the prolamin analysis and toxicity, 2004; III Symposium: 147-9

2002 2002 Malaria: The dilemmas of malarial diagnostics. J R Army Med Corps 2002; 148: 122-126Malaria: The dilemmas of malarial diagnostics. J R Army Med Corps 2002; 148: 122-126

Research FellowshipResearch Fellowship

• St. Marks’ and St. Thomas’ St. Marks’ and St. Thomas’ HospitalHospital

• The Bacterial Pathogenesis of The Bacterial Pathogenesis of Pouchitis and Development of Novel Pouchitis and Development of Novel Probiotic Therapies Probiotic Therapies

• Prof PJ. Ciclitira, Prof RJ. Prof PJ. Ciclitira, Prof RJ. Nicholls and Nicholls and Prof A. Forbes Prof A. Forbes

• MD – Awaiting ExaminationMD – Awaiting Examination

AimsAims

•IBD Centre of Excellence IBD Centre of Excellence

•SBCE SBCE

•HRMHRM

•EUSEUS

LuminologyLuminology

To the ileum …and beyondTo the ileum …and beyond

OesophaguOesophaguss

High Resolution ManometryHigh Resolution Manometry

• Spatiotemoral plots derived from Spatiotemoral plots derived from >36 closely spaced pressure sensors>36 closely spaced pressure sensors

• Reveals complex functional anatomyReveals complex functional anatomy

• Increased our understanding of Increased our understanding of dysmotilitydysmotility

• Looks beautifulLooks beautiful

NormalNormal

AchalasiaAchalasia

Mid-oesophageal submucosal Mid-oesophageal submucosal CaCa

Herniation of Lap WrapHerniation of Lap Wrap

StomachStomach

Management of Dyspepsia Management of Dyspepsia BSG Guidelines 1996BSG Guidelines 1996

Updated 2002Updated 2002

ByBy

Matt JohnsonMatt Johnson

St. Thomas’s and East SurreySt. Thomas’s and East Surrey

Dyspepsia IntroductionDyspepsia Introduction

• Prevalence = 23 – 41% in UKPrevalence = 23 – 41% in UK

• 4% of GP consultations 4% of GP consultations

• 10% of these are referred to hospital10% of these are referred to hospital

• 2% of entire adult population receive 2% of entire adult population receive either an OGD or a barium meal each either an OGD or a barium meal each yearyear

Rationing of EndoscopyRationing of Endoscopy

• Morbidity = 1:1,000 (Haemorrhage)Morbidity = 1:1,000 (Haemorrhage)• Death = 1:10,000 (Perforation)Death = 1:10,000 (Perforation)

• OGD is recommended in all patients >55y OGD is recommended in all patients >55y DD

– with new onset uncomplicated dyspepsiawith new onset uncomplicated dyspepsia– for > 1/12 durationfor > 1/12 duration

• < 55y with “alarm symptoms”< 55y with “alarm symptoms” CC

Alarm SymptomsAlarm Symptoms

• These include dyspeptic patients with:These include dyspeptic patients with:– Unintentional weight lossUnintentional weight loss– GI BleedingGI Bleeding– Previous gastric surgeryPrevious gastric surgery– Epigastric massEpigastric mass– Previous gastric ulcerPrevious gastric ulcer– Unexplained Fe deficiencyUnexplained Fe deficiency– Dysphagia or OdynophagiaDysphagia or Odynophagia– Persistent continous vomitingPersistent continous vomiting– Suspicious barium mealSuspicious barium meal

Investigation of Investigation of dyspepsia in patients dyspepsia in patients

<55 years<55 years

NICE guidelines NICE guidelines www.nice.org CG17CG17

Test and treat HelicobacterTest and treat HelicobacterEmpirical PPI therapy Empirical PPI therapy Reduce role of endoscopy in the <55 yrsReduce role of endoscopy in the <55 yrsManage uninvestigated reflux as dyspepsiaManage uninvestigated reflux as dyspepsiaAlarm symptoms via TWWAlarm symptoms via TWW

February Surrey and Sussex Healthcare 2008 NHS Trust

724 endoscopies performed

54% normal

13% major abnormalities

33% minor abnormalities

42% recommended PPI therapy

8.1% helicobacter eradication resulting

1 oesophageal cancer discovered (aged 52) *

Investigation of dyspepsia in Investigation of dyspepsia in patients <55 yearspatients <55 years

Conclusions:

Three weeks out of year spend endoscoping this group

Findings in line with other studies

Very low prevalence of cancer in this group

Minimal evidence of change in management

Investigation of dyspepsia in Investigation of dyspepsia in patients <55 yearspatients <55 years

Iron Deficiency AnaemiaIron Deficiency Anaemia

Causes of Fe deficiency Causes of Fe deficiency AnaemiaAnaemia• Occult GI Blood LossOccult GI Blood Loss

– Aspirin/NSAID use Aspirin/NSAID use 10– 10–15%15%

– Colonic carcinoma Colonic carcinoma 5– 5–10%10%

– Gastric carcinoma Gastric carcinoma 5% 5%– Gastric ulceration Gastric ulceration 5% 5%– Angiodysplasia Angiodysplasia 5% 5%– Oesophagitis Oesophagitis 2–4% 2–4%– Oesophageal Ca Oesophageal Ca 1– 1–

2%2%– GAVE (ectasia)GAVE (ectasia) 1–2% 1–2%– Small bowel tumours 1–2%Small bowel tumours 1–2%– Ampullary Ca.Ampullary Ca. <1% <1%– Ancylomasta duodenale <1%Ancylomasta duodenale <1%

• MalabsorptionMalabsorption– Coeliac disease Coeliac disease

4–6%4–6%– GastrectomyGastrectomy <5% <5%– H. pylori colonisation <5%H. pylori colonisation <5%– Gut resection Gut resection <1% <1%– Bacterial overgrowth <1%Bacterial overgrowth <1%

• Non-GI blood lossNon-GI blood loss– Menstruation Menstruation 20–30% 20–30%– Blood donation Blood donation 5% 5%– Haematuria Haematuria 1% 1%– Epistaxis Epistaxis

<1%<1%

Iron Deficiency AnaemiaIron Deficiency Anaemia

• HaemoglobinHaemoglobin <12 or <13 nmg/L<12 or <13 nmg/L• MCVMCV <76<76• FerritinFerritin <15nmg/L<15nmg/L• Coeliac serologyCoeliac serology• TFTTFT• Sickle cell and Thalassaemia screenSickle cell and Thalassaemia screen• Non-vegetarianNon-vegetarian• No menorrhoeaNo menorrhoea

•Small Small BowelBowel

Matt Johnson + David DewarMatt Johnson + David Dewar

Professor Paul CiclitiraProfessor Paul Ciclitira

St Thomas’s Hospital, LondonSt Thomas’s Hospital, London

Prevalence of coeliac Prevalence of coeliac diseasedisease

• SwedenSweden 1:67 antibody positive1:67 antibody positive

• IrelandIreland 1:100 1:100

• England England 1:1501:150

• Europe Europe 1:3001:300

• N America N America 1:3001:300

• AustraliaAustralia1:3001:300

DERMATITIS HERPETIFORMIS

AssociationsAssociations

• Dermatitis herpetiformisDermatitis herpetiformis• IgA deficiencyIgA deficiency 2-3%2-3%• SBBOSBBO 8% of NRCD8% of NRCD• Hyposplenism Hyposplenism ?80%?80%• Microcytic colitis Microcytic colitis 5%5%• Autoimmune conditionsAutoimmune conditions 25%25%

– Thyroid diseaseThyroid disease– Type 1 diabetesType 1 diabetes– Addison’sAddison’s– Sjogrens syndromeSjogrens syndrome

AD and age at diagnosis:AD and age at diagnosis:

GroupGroup Prevalence ADPrevalence AD

A1 – age<2yrsA1 – age<2yrs 5.1%5.1%

A2 – age 2-10yrsA2 – age 2-10yrs 17%17%

A3 – age>10yrsA3 – age>10yrs 23.6%23.6%

• Prevalence of autoimmune disease is Prevalence of autoimmune disease is related to duration of gluten exposurerelated to duration of gluten exposure

Ventura A (1999) Gastroenterology 117:297-303

OsteoporosisOsteoporosis

• 47% women < 50% men on GFD have 47% women < 50% men on GFD have osteopenia / osteoporosisosteopenia / osteoporosisaa

• Improvement 1 year post treatmentImprovement 1 year post treatmentbb

aMcFarlane (1995) Gut 36:710-14bValdimarsson (1996) Gut 38:322-7

MortalityMortality

• Almost all mortality in CD is due to Almost all mortality in CD is due to malignancymalignancy

• >50% due to EATCL >50% due to EATCL

• Other tumours = mouth, oesophagus, sb,lbOther tumours = mouth, oesophagus, sb,lb

• Mortality 1.9-3.4x control populationMortality 1.9-3.4x control population

• Holmes et al : 2x control popHolmes et al : 2x control pop11

• Mortality normal after 5 yrs on GFDMortality normal after 5 yrs on GFD22

1Holmes GK et al (1976) Gut 17(8): 612-92Holmes GK et al (1989) Gut 30(3): 333-8

Ulcerative jejunitisUlcerative jejunitis

• Rare (6Rare (6thth decade) pre-malignant state decade) pre-malignant state

• Related to Enteropathy-associated T cell Related to Enteropathy-associated T cell lymphoma (EATL)lymphoma (EATL)

• T Cell receptor PCR T Cell receptor PCR monomonoclonalityclonality– UCL – Prof. IsaacsonUCL – Prof. Isaacson– Atypical gTcell receptor abnormalitiesAtypical gTcell receptor abnormalities

• Steroids, nutritional support, close Steroids, nutritional support, close observationobservation

Treatment of coeliac Treatment of coeliac diseasedisease• Gluten-free dietGluten-free diet• Avoidance of wheat, rye and barleyAvoidance of wheat, rye and barley• Oats (probably OK)Oats (probably OK)• DieticianDietician• Codex Codex AAlimentariuslimentarius• Coeliac societiesCoeliac societies handbook handbook

• BUT NOT CORNFLAKESBUT NOT CORNFLAKES

Using Serology to Monitor Using Serology to Monitor PatientsPatients

• IgA gliadin and TTG normalise on a IgA gliadin and TTG normalise on a strict GFD after 3-6/12strict GFD after 3-6/12

• Must have pre-treatment levelsMust have pre-treatment levels

• IgG gliadin can be used but takes IgG gliadin can be used but takes longer to normaliselonger to normalise

• IgA endomyseal is costly and more IgA endomyseal is costly and more difficult to quantifydifficult to quantify

Dewar D, Johnson MW, Ciclitira PJ, GUT 2005

Small BowelSmall Bowel• UGI tract UGI tract 0.8m0.8m

• LGI tract LGI tract 1m1m

• SbSb 5.6m 5.6m

95% absorption 95% absorption capacitycapacity

A small disposable capsule about the size of a jelly bean.Has own light source and video camera.Suitable for adults and older children.Transmits data to recorder worn at waist.Patient swallows capsule with glass of water after a simple overnight fast. Carries on with normal activities and returns data recorder after 8 hours.

Capsule EndoscopeCapsule Endoscope

BSG Indications for SBCEBSG Indications for SBCEGuidelines April 2008Guidelines April 2008  

1) Obscure gastrointestinal bleeding1) Obscure gastrointestinal bleeding

2) Suspected sb Crohn’s disease2) Suspected sb Crohn’s disease

3) Assessment of Coeliac disease3) Assessment of Coeliac disease

4) Screening for Polyps / FAP4) Screening for Polyps / FAP

• Suspected small bowel malignancySuspected small bowel malignancy

• Evaluation of side-effects of NSAIDsEvaluation of side-effects of NSAIDs

Dartford SBCE ServiceDartford SBCE Service

A review of the first 37 small bowel capsule enteroscopies performed at Darent Valley Hospital.A review of the first 37 small bowel capsule enteroscopies performed at Darent Valley Hospital.

Stomach Stomach • Gastritis (5)Gastritis (5)• Erosions (6)Erosions (6)• Angiectasia (4) Angiectasia (4) • Polyps (1) Polyps (1)

Small bowel Small bowel • NSAID induced enteropathy (9)NSAID induced enteropathy (9)• Angiodysplasia (2)Angiodysplasia (2)• Coeliac disease (7) Coeliac disease (7) - UCH pre-malignant ulcerative jejunitis- UCH pre-malignant ulcerative jejunitis• Gastrointestinal stromal tumours (GISTs) (2) Gastrointestinal stromal tumours (GISTs) (2) - 2x St. Mark’ for D-balloon enteroscopy - 2x St. Mark’ for D-balloon enteroscopy • Crohn’s disease (5) Crohn’s disease (5) • Juvenile polyposis (1)Juvenile polyposis (1) - GOS- GOS• Bacterial overgrowth secondary to small bowel diverticulae (1)Bacterial overgrowth secondary to small bowel diverticulae (1)• Parasitic infestation (1)Parasitic infestation (1)• Multiple cystic lymphangiectasia (1) Multiple cystic lymphangiectasia (1)

Coeliac DiseaseCoeliac Disease

Using SBCE in Crohn’sUsing SBCE in Crohn’s

• 10-30% 10-30% sb only sb only • 66% 66% ileocaecal diseaseileocaecal disease• 20% 20% coloniccolonic

• Wireless capsule endoscopy and Wireless capsule endoscopy and Crohn’s disease. P SwainCrohn’s disease. P Swain

• Gut: March 2005 vol 54 no 3Gut: March 2005 vol 54 no 3

Suspected Crohn’s Suspected Crohn’s

Obscure Intestinal Bleeding

5% of all UGI haemorrhages

Benefits

Safe, well tolerated, able to view entire small bowel, clarity of image + Share images; patient preference;

Reduced diagnostic cost and utilization

If bleeding source identified = Less need for transfusions

Reduced treatment cost and utilization

Small bowel malignanciesSmall bowel malignancies

Prior to SBCE sb tumours = 1 - 2% of all GI malignancies

Now it is thought to compromise 5%

PillCam™ Trial = incidence of small bowel tumors among 1,235 patients – 6% - 9% (Corbin, Bailey, Keuchel)

60% of SBTs are malignant- adenocarcinomas, carcinomas, melanomas,

lymphomas and sarcomas40% of SBTs are benign

GISTs, hemangiomas, hamartomas, and adenomas

Small Bowel malignanciesSmall Bowel malignancies

Often diagnosed late or incidentally at laparotomy Malignant tumors of small bowel (poor prognosis)

Metastases - 45% - 75%Unresectable - 20% - 50%

80% of SBTs undergoing SBCE present with obscure GI bleeding/anemia Improved outcome of earlier diagnosed tumors in the small bowel

On average patients with SBTs who present for SBCEs have already undergone detected SBTs after patients had undergone an average of 4.6 negative endoscopic procedures

PillCam™ Trial (Corbin, Bailey, Keuchel)

Final pointsFinal points

• Safe + Well tolerated Safe + Well tolerated • Cost-effective in economic analysis.Cost-effective in economic analysis.

• This is now standard practice throughout UKThis is now standard practice throughout UK• Watford, Stevenage, Wellen Garden City, Watford, Stevenage, Wellen Garden City,

Cambridge, ?AylesburyCambridge, ?Aylesbury

• Presently the paediatricians refer to GOSPresently the paediatricians refer to GOS• Adult medicine is under-referring St.Mark’sAdult medicine is under-referring St.Mark’s• External referral = £800-1200External referral = £800-1200• Cost of service = £13,000Cost of service = £13,000• Cost of capsule = £340 Cost of capsule = £340

ColonColon

Operative PictureOperative Picture

ComplicationsComplications

• ObstructionObstruction

• BleedingBleeding

• Inflammation “itis”Inflammation “itis”– Fistula Fistula – SepsisSepsis– Perforation Perforation

• May co-exist with IBDMay co-exist with IBD Specimen showing blood in diverticulae

Criteria for Toxic MegacolonCriteria for Toxic Megacolon

((Jalan et al)Jalan et al)

• 1) 1) Radiographic evidence Radiographic evidence – Total or segmental non-obstructive colonic dilatation of Total or segmental non-obstructive colonic dilatation of

> 6cm> 6cm• 2) 2) 3 or more of:3 or more of:

– Fever > 38 CFever > 38 C– PR > 120 / minPR > 120 / min– Neutrophils > 10.5Neutrophils > 10.5– Hb <12.5Hb <12.5

• 3) 3) At least 1 of:At least 1 of:– DehydrationDehydration– HypotensionHypotension– Electrolyte imbalanceElectrolyte imbalance– Altered consciousnessAltered consciousness

Probiotics are sooo outdatedProbiotics are sooo outdated

• Prebiotics = “functional foods” Prebiotics = “functional foods” • Inulin / Fructo-oligosaccharides / Lactulose Inulin / Fructo-oligosaccharides / Lactulose

Transgalacto-oilgosaccharidesTransgalacto-oilgosaccharides

• Chicory (boiled root = 90% inulin)Chicory (boiled root = 90% inulin)• Jerusalem artichokeJerusalem artichoke• Onion Onion • LeekLeek• GarlicGarlic• AsparagusAsparagus• BananaBanana• (cereals eg. Oatmeal)(cereals eg. Oatmeal)