Gastroenterology Today Autumn 2020

Volume 30 No. 3
Autumn 2020
Gastroenterology Today
ENDOSCOPY ALTERNATIVES
IN A TIME OF COVID
What approach has 18 Week Support
taken with regards to building an
expert insourcing team?
Matthew’s Perspective:
Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. He believes it starts with recruiting the
best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well
above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data
is an excellent quality indicator, we now want to go a step beyond that and monitor the Non-Technical skills (NTS) of each
clinician as well. We now know that NTS plays an important role in safe and effective team performance. Therefore, in our
quest to develop excellent teams who deliver a world-class service, we must focus on NTS’.
Tammy and Lisa’s Perspective:
Tammy Kingstree is Lead Nurse for Endoscopy.
‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from
our senior nurse coordinators who are trained to manage the patient pathway, manage a team of staff they may not know
and to deal effectively with any issues which may arise on the day’.
Lisa Phillips is Lead Nurse for Endoscopy.
‘The team objectives are clear. Excellent patient experience and good patient outcomes. Because the objectives are clear,
team cohesion and focus are exceptionally good. It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit,
the service should be seamless. If it isn’t, we do not stop until we get it right.
If you have an excellent NHS record and want to help clear NHS waiting list backlogs, reduce RTT waiting times and provide
18 Week Support Gastroenterology:
Partnering to Succeed
high-quality patient care, get in touch by calling on 020 3892 6162 or email Gastro.Recruitment@18weeksupport.com
Dr Matthew Banks
Clinical Lead for Gastroenterology

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CONTENTS
CONTENTS
5 EDITORS COMMENT
6 FEATURE Transplantation during the COVID-19 pandemic:
Matthew’s Perspective:
nothing noble is accomplished without danger
12 FEATURE Rethinking how we treat constipation in the UK
16 NEWS
22 COMPANY NEWS
COVER STORY
ENDOSCOPY ALTERNATIVES IN A TIME OF COVID – Innovative thinking
and different ways of working to clear NHS Trusts Waiting Lists
Gastroenterology Today
What approach has 18 Week Support
taken with regards to building an
expert insourcing team?
This issue edited by:
Dr Andrew Poullis
c/o Media Publishing Company
Media House
48 High Street
Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. SWANLEY, He believes Kent it starts BR8 with recruiting 8BQ the
best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well
above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data
is an excellent quality indicator, we now want to go a step beyond that and ADVERTISING monitor the Non-Technical & CIRCULATION:
skills (NTS) of each
clinician as well. We now know that NTS plays an important role in safe and Media effective Publishing team performance. Company
Therefore, in our
quest to develop excellent teams who deliver a world-class service, we must Media focus on House, NTS’. 48 High Street
SWANLEY, Kent, BR8 8BQ
Tammy and Lisa’s Perspective:
Tammy Kingstree is Lead Nurse for Endoscopy.
Tel: 01322 660434 Fax: 01322 666539
‘It is extremely important that there are good working relationships within E: the info@mediapublishingcompany.com
team. This starts with strong leadership from
our senior nurse coordinators who are trained to manage the patient pathway, manage a team of staff they may not know
www.MediaPublishingCompany.com
and to deal effectively with any issues which may arise on the day’.
Lisa Phillips is Lead Nurse for Endoscopy.
PUBLISHING DATES:
‘The team objectives are clear. Excellent patient experience and good patient March, outcomes. June, Because September the objectives and are clear, December.
team cohesion and focus are exceptionally good. It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit,
the service should be seamless. If it isn’t, we do not stop until we get it right.
COPYRIGHT:
If you have an excellent NHS record and want to help clear NHS waiting list Media backlogs, Publishing reduce RTT waiting Company
times and provide
high-quality patient care, get in touch by calling on 020 3892 6162 or email Gastro.Recruitment@18weeksupport.com
Media House
48 High Street
SWANLEY, Kent, BR8 8BQ
PUBLISHERS STATEMENT:
The views and opinions expressed in
this issue are not necessarily those of
the Publisher, the Editors or Media
Publishing Company.
For the next 12 months and probably longer, the impact of COVID on diagnostic
pathways will have far reaching effects on waiting lists and time to diagnosis.
Diseases of the gastrointestinal tract can have a devastating impact on health
so rapid diagnosis and management of these diseases is vital to ensure positive
outcomes for patients.
Exploring alternative diagnostic technologies should be a vital component for the
NHS in assessing new strategies to cope with this significant increase in demand,
especially where they can deliver results quickly, safely and cost-effectively.
Endoscopy has not been immune from technological innovation, for example
FIT, Cytosponge and Pillcam. Each of these offers some cost, accuracy or other
benefits to Trusts at this time, and we propose to review these in subsequent
editions. However, in this edition we start with Transnasal endoscopy as our first
alternative technology to be explored.
We know it can be deployed safely and easily in outpatient settings, and at this time
any keeping patients and surgical teams separate from hospital red zones is an
important advantage at this current time.
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3

EDITORS COMMENT
EDITORS COMMENT
Covid Collateral
The health and economic impacts of Covid are increasingly being understood. In addition
to the obvious direct costs the collateral damage is starting to become evident.
“The
longer term
consequences
of this
pandemic
may not yet
be evident.”
Some of this collateral damage, with delays in diagnosis and treatments, is obvious and
hopefully relatively short lived. The longer term consequences of this pandemic may not yet
be evident.
The unprecedented cessation of diagnostic endoscopy has led to the build up of enormous
waiting lists. Trusts are struggling to tackle these for new patients but of equal concern is
the collateral damage “2nd wave” of delays to surveillance patients. Endoscopic follow up
of Barrett’s, IBD, colorectal cancer and colonic polyps constitutes a large volume of work
within luminal gastroenterology. The gains made in endoscopy quality are at risk if the false
solution of overbooking lists (as has been suggested) to deal with this waiting list issue are
forced through. A high quality service needs time, correctly trained staff and the appropriate
physical space to deliver the service - this is just as true of radiology and out-patient
services as it is to endoscopy.
While the NHS doesn’t need re-building it certainly needs quite a bit of maintenance -
without this the legacy of Covid is likely to be more protracted than the duration of the
pandemic.
A Poullis
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5

FEATURE
TRANSPLANTATION DURING THE
COVID-19 PANDEMIC: NOTHING NOBLE
IS ACCOMPLISHED WITHOUT DANGER
Gabriele Spoletini 1* , Giuseppe Bianco 1 , Dario Graceffa 2 and Quirino Lai 3
Spoletini et al. BMC Gastroenterology (2020) 20:259 https://doi.org/10.1186/s12876-020-01401-0 © The Author(s). 2020
GASTROENTEROLOGY TODAY - AUTUMN 2020
6
Abstract
The global health crisis due to the fast spread of coronavirus disease
(COVID-19) has caused major disruption in all aspects of healthcare.
Transplantation is one of the most affected sectors, as it relies on a
variety of services that have been drastically occupied to treat patients
affected by COVID-19. With this report from two transplant centers
in Italy, we aim to reflect on resource organization, organ allocation,
virus testing and transplant service provision during the course of
the pandemic and to provide actionable information highlighting
advantages and drawbacks. To what extent can we preserve the noble
purpose of transplantation in times of increased danger? Strategies to
minimize risk exposure to the transplant population and health- workers
include systematic virus screening, protection devices, social distancing
and reduction of patients visits to the transplant center. While resources
for the transplant activity are inevitably reduced, new dilemmas arise to
the transplant community: further optimization of time constraints during
organ retrievals and implantation, less organs and blood products
donated, limited space in the intensive care unit and the duty to
maintain safety and outcomes.
Keywords:
Coronavirus, Transplantation, Organ donation, SARS-CoV-2, COVID-19,
Virus tests.
Background
Since December 2019, the fast spread of the novel Severe Acute
Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2) causing a severe
acute respiratory disease (COVID-19), has determined a healthcare
crisis in a growing number of countries. To date, USA, Spain and Italy
have reported the highest number of patients affected, and COVID-19
has been categorized as a global pandemic [1]. Disruptions in
almost all aspects of health care provision have been observed, and
health systems are trying to continue offering essential services while
suspending those that can be postponed.
Transplant services can be categorized depending on their lifesaving
nature. Heart, lung and liver transplants are urgent lifesaving operations
in a proportion of wait-listed patients. In particular, those with chronic
end-stage organ disease who develop deterioration of their baseline
condition, and those who suffer from sudden end-stage failure of a
given organ.
*
Correspondence: gabriele.spoletini@policlinicogemelli.it
1
General Surgery and Liver Transplantation, Fondazione Policlinico
Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
While it seems obvious that lifesaving transplant activity should not
be stopped, it is not clear whether nonlifesaving transplants should
be delayed past the most critical phase of the emergency. In fact,
prolonging the time spent on the waiting list can translate into waiting list
drop-out due to disease progression or overcoming contra-indications.
On May 3, 2020, Italy is the third most affected country worldwide
and has registered the second highest number of COVID-19-related
deaths so far. The Italian National Authority for Transplantation released
guidance on donor and recipient testing for SARS-CoV-2 [2, 3]. Testing
via naso-pharyngeal swab (NPS) or bronchoalveolar lavage and, if
positive, measurement of viral load on blood sample are recommended
in all donors from high incidence regions. SARS-CoV-2 positive potential
deceased donors are to be discarded and living donors postponed.
NPS is compulsory before transplantation for all potential recipients who
are symptomatic or with a history of contact with a COVID-19 positive
patient, and discretional for asymptomatic recipients in whom history of
contact with COVID-19 positive patient can be reasonably ruled out.
Implications of the spread of COVID-19 for the transplant community
are innumerable, and the unprecedented nature of the pandemic has
left physicians without guidance in many of their management choices.
Balancing resource constraints, patient safety and life-saving organs
demand is difficult during COVID-19 pandemic. With the present report
we aim to reflect on the open challenges for the transplant community.
A summary of actions to be undertaken is summarized, reflecting on
advantages and dangers related to each (Table 1).
Screening and risk exposure for transplant staff
Since the beginning of the pandemic, health-workers screening
has been advocated as an essential tool for: 1) protecting patients
from staff-mediated transmission and 2) protecting health-workers
allowing prompt treatment. In the setting of transplantation, the first is
of paramount importance, being the immunosuppressed population
more vulnerable to infections. As of February 11, 2020, out of 44,672
confirmed COVID-19 cases in Mainland China, 1716 (3.8%) cases were
health-workers [4]. To date, 21,338 health-workers have tested positive
for SARS-CoV-2 in Italy and 154 doctors (including retired ones) and
40 nurses lost their lives after being infected [5]. Shortage of personal
protection devices and work overload have contributed to increase
the rate of contagion within health-workers. Hosts of SARS-CoV-2 may
transmit the virus while they are asymptomatic or during the incubation
period, a mechanism that creates a vicious circle of in-hospital disease
spread to patients and staff. Testing all the transplant staff (or, at least,
those who come into contact with transplanted patients) could mitigate

FEATURE
Table 1 Summary of issues and actions to be undertaken to mitigate the risks for the transplant population and staff related to
COVID-19
Issues and actions Advantage Disadvantage
Screening and risk exposure for transplant staff
Extensive screening of transplant staff
Travels reduction – regional organs shipping systems
Timing and logistics of transplantation
Screening of waitlisted patients
Healthcare workers safety
Breaking the vicious circle of in-hospital virus
transmission
Reduction of contagion to other hospitals
from travelling retrieval surgeons
Thorough information regarding patients
awaiting transplants
Increased costs
More staff quarantined
Need to develop a graft exchange
system if not in place yet
Costs
Logistics of testing for patients
currently out-of-hospital
Recipients testing at the time of transplant offer Lower costs compared to previous action Delays before transplant start
Possible cancellation of recipient’s
transplant
Back-up recipient in hospital
Use of machine perfusions to fast-track organ retrieval from
unstable donors (applicable only to donors with low-risk
COVID-19 history)
Teleclinics for follow-up of transplant recipients
Transplant benefit
Revisiting local policies of access to transplantation based
on hospital resources availability
• Privileging “utility” (recipients with expected better
outcomes)
• Privileging “urgency” (recipients with the highest need)
Prompt replacement if first candidate tests
positive
Extended preservation time
Higher organs yield
Avoiding access to hospital out-patient clinics
- decreased exposure to infection
Realistic approach to resource allocation
between COVID and non-COVID diseases
• Less resource consumption (faster ICU
turnaround, less blood transfusions, etc.)
• Treating the sickest patients only and utilize
resources for those in desperate need of
transplantation
More complex logistics
Anxiety and potential frustration for
most back-up patients
Increased logistics costs.
Increased costs
Aborted procedures if COVID-19 tests
return positive
Increased risk of missing potentially
relevant yet subclinical health
problems
Further stretching healthcare
resources with risk of system collapse
• Missing the sickest patients;
increased mortality without treatment
• Uncertainty regarding mortality
effect at the “bottom” of the
transplant waiting list
the risk of in-hospital transmission at the price of increased costs and
workload for already under-pressure health systems. In Italy, during the
fast-growing spread of COVID-19 in March, the lack of tests did not
allow to adopt such an extensive screening policy.
countries where social distancing measures have been in place for as
long as the median virus incubation time, have the opportunity to rule
out possible false negative tests from recipients who have complied with
the social restriction policy [6, 7].
In addition, transplant teams are at higher risk of contagion as they might
travel to high incidence areas when retrieving organs for transplantation.
Some countries do not have a centralized organ retrieval system and
transplant teams travel outside their regions to procure organs they
will implant. A “travelling organs” policy such as in the National Organ
Retrieval System in the United Kingdom or Euro-transplant in central
Europe help avoid transplant teams travelling from low to high incidence
regions and contain the spread within medical staff. In our region, liver
transplant centers based in Rome share an organ procurement scheme
to retrieve and ship organs to other centers in Italy. Most regions in Italy
have implemented a regional organ sharing system which, during the
COVID-19 pandemic, has been increasingly utilized.
Timing and logistics of transplantation
Due to the relevant number of false negative viral tests, there is a
consistent risk of transplanting recipients who are either asymptomatic
or in the incubation phase. This mandates caution and candidates
for transplantation are delayed if their condition allows to. However,
Success of transplantation relies on optimization of time constraints. The
additional time required for COVID-19 testing of donors and recipients
may delay organ procurement and lower the utilization rate especially
of hemodynamically unstable donors that normally require fast-track
management to minimize organs damage. Machine perfusion for organ
preservation is expanding in almost all solid organs transplantation,
allowing extend preservation time in liver, kidney, lung and heart
transplantation [8, 9]. Machine perfusion could come into help when
organs need to be retrieved quickly and preserved while virus tests
are processed, in particular in unstable donors with low-risk history for
COVID-19.
In an effort to minimize the possibility of delays which cause prolongation
of cold ischemia time, back-up transplant candidates have been called
in as a routine policy by several transplant centers when issues with the
first-choice candidate are anticipated. Implementing such policy during
the COVID-19 outbreak could offer the possibility to quickly replace the
first candidate if they turn out to be SARS-CoV-2 positive.
GASTROENTEROLOGY TODAY - AUTUMN 2020
7

FEATURE
Table 2 Diagnostic tests available in Italy to detect SARS-CoV-2 infection
Method
Real time reverse
transcriptionpolymerase
chain
reaction
Direct amplification
real-time reverse
transcriptionpolymerase
chain reaction.
Diasorin
Simplexa
Solid phase immunochromatographic
assay for the detection
of IgG and IgM
antibodies to SARS-
CoV-2.
Type of specimen
required
Respiratory and
non-respiratory
tract specimens
Nasopharyngeal
swabs
Whole blood,
serum or plasma
Time required for assay Advantages
5–8 h Gold standard for the etiological
diagnosis; high sensitivity and
specificity; high safety
1 h High sensitivity and specificity;
simple protocol with all in one
reagent; rapid response; high
safety; suitable for decentralized
point-of-care
5–15 min No equipment needed; rapid
response; suitable for decentralized
point-of-care; good sensitivity and
specificity; suitable for identifying
asymptomatic patients and for
screening
Limits
Complex protocol; overcoming of the
throughput capacities of the laboratories
with diagnostic delays; not suitable for
decentralized point-of-care
For emergency use authorization only;
Limited literature data; Limited to
laboratories certified to perform high
complexity tests
Not recommended as first line test for
the diagnosis of acute viral infection;
prone to ‘cross reactivity’; few reports
about serological assay in detection of
SARS-CoV-2; uncertain timing of antibodies
development
GASTROENTEROLOGY TODAY - AUTUMN 2020
8
Remote outpatient clinics via telephone or video calls (tele-clinics)
are increasingly utilized to reduce hospital congestion and seminal
experiences in kidney transplantation have registered even higher
attendance rates than conventional clinics in selected patients [10].
Converting a proportion of outpatient clinics appointments to tele-clinics
may reduce transplant population exposure to the virus. Numbers of
visits (even tele-visits) can be reduced selecting only those patients
with new symptoms or active issues, delaying well-being ones. A
policy of remote management of immunosuppression by testing
immunosuppressant level in local laboratories (then transmitted
electronically) can be encouraged, thus relieving the workload on
transplant centers.
Virus tests and transplantation
In transplant services, a delay or failure to diagnose SARS-CoV-2 infection
in a donor may potentially produce disastrous consequences for the
recipient and also increase the risk for health-workers [11]. In this context,
the role of in vitro diagnostics is crucial to screen donors and recipients.
An appropriate diagnostic strategy for the detection of virus infection
involves collecting the correct specimen from the patient at the right time
and performing an accurate and rapid laboratory test (Table 2).
Reverse transcription-polymerase chain reaction
The gold standard technique for detecting the SARS-CoV-2 infection
is the real-time polymerase chain reaction (RT-PCR). This test has
the advantage that the primers required can be produced as soon
as the viral sequence is known. RT-PCR provides high levels of
diagnostic sensitivity and specificity but the test protocol of nucleic
acid amplification is complex and requires specialized instruments
and technicians [12]. Although SARS-COV-2 RNA has been detected
from a variety of respiratory sources, US Centers for Disease Control
and Prevention recommends collecting only the upper respiratory NPS
[13]. This indication is in accordance with Wang et al., that reported
good detection rates of SARS-CoV-2 RNA in NPS (63% of the examined
samples) [14]. SARS-CoV-2 RNA has been also detected from feces
and blood specimens, although less reliably than from respiratory
specimens. Higher viral loads have been detected soon after symptoms
onset; thus, respiratory specimens should be collected within the first
7 days. Missing the time-window of viral replication can cause false
negative results [15, 16]. Several RT-PCR protocols for the detection of
SARS-CoV-2 RNA have been released by the World Health Organization
and nowadays are widely standardized. However, work overload and
logistic difficulties to ship samples to the few specialized centers,
lead to significant delays in response time (up to 4–5 days in remote
hospitals) [17]. This has caused issues in transplant services where
rapid tests are needed to accelerate clinical decision-making. Several
new generation real-time RT-PCR protocols for the detection of SARS-
COV-2 RNA have been recently developed. These assays are suitable
for decentralized point-of-care use and allow obtaining reliable results
within 1 h (actual state-of-the-art detection methods). One of these,
Simplexa COVID-19 Direct (DiaSorin Molecular LLC, CA) received
the FDA’s emergency use authorization and it is nowadays available in
Italy. Simplexa incorporate nucleic acid extraction, amplification and
detection together into an integrated system ensuring a simple, safe
and highly qualitative test [18–20].
Serology
A recent study reported acute antibody responses to SARS-CoV-2 in
285 patients and clarified that antibodies produced during the course
of infection by symptomatic and asymptomatic patients can aid to the
diagnosis of COVID-19 [21]. Immunoassays for detection of SARS-
COV-2 immunoglobulin (Ig) M and IgG antibodies have proven to be
highly specific and sensitive providing diagnostic evidence of infection
in a few minutes. Moreover, the use of serology rapid tests could
facilitate the diagnosis of SARS-CoV-2 infections when the molecular
assays were performed unsatisfactorily [22, 23]. Several companies,
driven by the growing demand of healthcare systems started to
produce rapid immunoassays for SARS-CoV-2. The majority of these
are solid phase immunochromatographic assays for the qualitative
and differential detection in human whole blood, serum or plasma of
IgG and IgM antibodies to SARS-CoV-2. Although the manufacturers
guarantee an accuracy close to 100%, doubts exist in the scientific
community about the time kinetics of humoral response and for the
potential cross reactivity with other coronaviruses [24]. In our opinion,
active surveillance with rapid serological tests may prove a good option
for the screening of asymptomatic donors and recipients.

FEATURE
Transplant benefit during the pandemic
Limited resources allocation is the mainstay of patient care during
catastrophes. When multiple casualties present at the same time,
patients are triaged and treatments offered based on the chance
of success. With the growing COVID-19 pandemic, the capacity of
many intensive care units (ICU) has been saturated, which forced
physicians to adopt a strict selection of patients who can be treated.
Transplantation has always faced the issue of limited resources due
to the scarcity of donors and the growing demand of organs. In liver
transplantation, the concept of transplant benefit has gained wide
acceptance in the last decade, in an effort to guarantee equity during
organs allocation, counterbalancing the principles of utility (recipients
with the highest chances of a good outcome) and urgency (recipients
with the biggest need of transplantation) [25, 26].
The widespread of COVID-19 has already caused a drastic reduction
in organ donation and this is predicted to aggravate further in the
next months. Times of further restraints stimulate reconsidering
principles of allocation and adopt a pragmatic approach based on the
available resources. A drop in the availability of blood products due
to the reduction in blood donors has been registered too. Restricting
transplants only to the sickest recipients (unbalancing towards the
“urgency” principle) could address the need of patients at imminent
risk of death from end-stage organ failure. However, it is not known
how this will increase mortality rates on the waiting list for all other
patients who are delayed (i.e., those at “the bottom of the list”). As an
example, patients with model for end-stage liver disease (MELD) of
30 have a 62% mortality rate without liver transplantation at 3 months
while the rate drops to 25% with a MELD of 20. On the contrary,
privileging liver transplant candidates with higher chances of success
and therefore shorter hospital stay and lower consumption of blood
transfusion (unbalancing towards the “utility” principle) would reduce
the workload on ICUs, at the price of excluding the sickest candidates.
Liver transplant recipients with MELD ≥30 have been shown to require
about double the amount of perioperative blood transfusion and days
of ICU stay compared to patients with MELD < 30 [27]. As happened in
the past, it should be noted that wait-listed patients might be reluctant to
undergo a transplant during the course of epidemics, especially those
whose disease is not as severe to threaten life in the short-term [28].
A “phased approach” to decreasing transplant activity has been
proposed, with varying degrees of reduction depending on resource
availability [29]. In addition, for the continuation of a transplant
programme, a “clean path” within the ICU has to be maintained and not
all hospitals might be in a condition to offer it.
During the SARS outbreak in 2003 some transplant centers closed their
activity temporarily and donor assessment guidelines were developed
to mitigate the risk related to donor selection [30]. During the Ebola
epidemic in 2014, the specifics of travel history of potential donors
were thoroughly assessed by the organ procurement organizations.
At that time, the high lethality of Ebola kept the number of affected
people relatively low and the impact on organ donation was contained.
The lack of effective treatments for Ebola stimulated the ethical debate
around the value of the informed consent to transplantation in times of
epidemics: a recipient might be willing to accept the risk of infection to
gain the benefit of a new organ, however this does not contemplate the
risk of infection spread to health-workers [31].
In the United Kingdom, the national authority for transplantation has
released clinical advice on donation acceptance criteria (deceased
donors will be considered only if < 50 and < 60 years of age
respectively for circulatory- and brain-dead donors). Most non-lifesaving
transplant programmes such as pancreas and living-donor kidney
have been put on hold [32]. In Switzerland, almost all non-lifesaving
transplants have been suspended. Other countries have advised in
favor of a case-by-case decision on both donation and transplantation,
depending on local conditions.
So far, most countries have reported a heterogeneous distribution of
COVID-19 across their regions, with foci of high incidence of contagion
causing major disruption to social life and healthcare. In a recently
published article, Michaels et al. suggested to redistribute patients
on the waiting list in endemic regions to less affected areas [33].
Such approach offers the advantage of not penalizing patients on the
waiting list only because of their geographical distribution, however,
in a rapidly changing scenario, less affected areas may need to keep
their resources available for possible sudden increases in hospital beds
demand.
Conclusions
COVID-19 pandemic is an unprecedented life-changing crisis causing
disruption in all the aspects of social life, especially for the wealthier
economies of the world. As our health systems are built around patientcentered
care, a cultural switch towards society over individual benefit
seems mandatory in order not to run out of resources and guarantee
the survival of our communities [34]. Stringent measures have been
put in place to control the disease spread. Transplantation is one of the
biggest advances in medical care and achievements in human history,
a noble discipline that has crossed dangerous paths for the sake of its
development. In this time of global crisis, the whole transplant community
is called to join forces and develop strategies to mitigate risks and
continue delivering the best possible results with the available resources
to the multitude of patients awaiting organs from all over the world.
Abbreviations
COVID-19: Coronavirus disease-19; ICU: Intensive care unit; Ig: Immunoglobulin;
MELD: Model for end-stage liver disease; MERS: Middle East respiratory
syndrome; NPS: Naso-pharyngeal swab; RNA: Ribonucleic acid; RT-PCR: Reverse
transcription-polymerase chain reaction; SARSCoV2: Severe acute respiratory
syndrome Coronavirus 2
Acknowledgements
None.
Authors’ contributions
GS, GB, DG and QL were responsible for the conception, design and analysis
of the study; GS, GB and DG were involved with the writing of the manuscript,
collection and interpretation of data; QL was involved in the writing, reviewing and
editing of the manuscript. All authors have read and approved the manuscript.
Funding
This study was not supported by any funding.
Availability of data and materials
The data used and analyzed during the current study are extrapolated and
available from the cited articles as listed in the “Reference” section. If requested by
the editors, we will provide the data and information on which the conclusions of
this manuscript are based.
GASTROENTEROLOGY TODAY - AUTUMN 2020
9

FEATURE
GASTROENTEROLOGY TODAY - AUTUMN 2020
Ethics approval and consent to participate
The study is a narrative review and represents the Authors’ opinions on the
subject. Direct patient data collection and participants consent were not
necessary.
Consent for publication
The study is a narrative review and represents the Authors’ opinions on the
subject. Direct patient data collection and consent to publish were not necessary.
Competing interests
GS and QL are members of the editorial board (Associate Editor) of BMC
Gastroenterology. GB and DG have no conflicts of interest to declare about the
present study.
Author details
1
General Surgery and Liver Transplantation, Fondazione Policlinico Universitario A.
Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy.
2
Centre for the Study and Treatment of Psoriasis, Department of Clinical
Dermatology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy.
3
Hepatobiliary and Organ Transplantation Unit, Sapienza University of Rome,
Umberto I Polyclinic of Rome, Rome, Italy.
Received: 8 May 2020 Accepted: 27 July 2020
References
1. Coronavirus disease 2019 (COVID-19) Situation Report – 104. https://www.
who.int/docs/default-source/coronaviruse/situation-reports/20200503-covid-
19-sitrep-104.pdf?sfvrsn=53328f46_2 Accessed 3 May 2020.
2. C_17_cntAvvisi_229_0_file.pdf. http://www.trapianti.salute.gov.it/imgs/C_17_
cntAvvisi_229_0_file.pdf. Accessed 4 Apr 2020.
3. C_17_cntAvvisi_234_0_file.pdf. http://www.trapianti.salute.gov.it/imgs/C_17_
cntAvvisi_234_0_file.pdf. Accessed 4 Apr 2020.
4. Team TNCPERE. The epidemiological characteristics of an outbreak of 2019
novel coronavirus diseases (COVID-19) — China, 2020. China CDC Wkly.
2020;2(8):113–22.
5. EpiCentro. Coronavirus | Istituto Superiore di Sanità. https://www.epicentro.
iss.it/coronavirus/. Accessed 3 May 2020.
6. Polak WG, Fondevila C, Karam V, et al. Impact of COVID-19 on liver
transplantation in Europe: alert from an early survey of European liver and
intestine transplantation association (ELITA) and European liver transplant
registry (ELTR). Transpl Int. 2020. doi:https://doi.org/10.1111/tri.13680.
Published online July 1, 2020.
7. Akdur A, Karakaya E, Ayvazoglu Soy EH, et al. Coronavirus disease
(COVID-19) in kidney and liver transplant patients: a single-center experience.
Exp Clin Transplant. 2020;18(3):270–4. https://doi.org/10.6002/ect.2020.0193.
8. Lai Q, Melandro F, Rossi M, Ruberto F, Pugliese F, Mennini G. Role of
perfusion machines in the setting of clinical liver transplantation: a qualitative
systematic review. Clin Transpl. 2018;32(8):e13310. https://doi.org/10.1111/
ctr.13310.
9. Yeung JC, Krueger T, Yasufuku K, et al. Outcomes after transplantation of
lungs preserved for more than 12 h: a retrospective study. Lancet Respir Med.
2017;5(2):119–24. https://doi.org/10.1016/S2213-2600(16)30323-X.
10. Udayaraj UP, Watson O, Ben-Shlomo Y, et al. Establishing a tele-clinic
service for kidney transplant recipients through a patient-codesigned quality
improvement project. BMJ Open Qual. 2019;8(2). https://doi.org/10.1136/
bmjoq-2018-000427.
11. Lai Q, Spoletini G, Bianco G, et al. SARS-CoV2 and immunosuppression:
A double-edged sword. Transpl Infect Dis. 2020:e13404. https://doi.
org/10.1111/tid.13404 Published online July 8, 2020.
12. Loeffelholz MJ, Tang Y-W. Laboratory diagnosis of emerging human
coronavirus infections - the state of the art. Emerg Microbes Infect. 2020:1–
26. https://doi.org/10.1080/22221751.2020.1745095 Published online March
20, 2020.
13. CDC. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control
and Prevention. Published February 11, 2020. https://www.cdc.gov/
coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html Accessed 27
Mar 2020.
14. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of
clinical specimens. JAMA 2020. doi:https://doi.org/10.1001/jama.2020.3786.
Published online March 11, 2020.
15. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory
specimens of infected patients. N Engl J Med. 2020;382(12):1177–9. https://
doi.org/10.1056/NEJMc2001737.
16. Wu JT, Leung K, Bushman M, et al. Estimating clinical severity of COVID-19
from the transmission dynamics in Wuhan, China Nat Med 2020:1–5.
doi:https://doi.org/10.1038/s41591-020-0822-7. Published online March 19,
2020.
17. National laboratories. https://www.who.int/emergencies/diseases/
novelcoronavirus-2019/technical-guidance/laboratory-guidance. Accessed
March 27, 2020.
18. Chan JF-W, Yip CC-Y, To KK-W, et al. Improved molecular diagnosis of
COVID-19 by the novel, highly sensitive and specific COVID-19-RdRp/Hel
real-time reverse transcription-polymerase chain reaction assay validated
in vitro and with clinical specimens. J Clin Microbiol 2020. doi:https://doi.
org/10.1128/JCM.00310-20. Published online March 4, 2020.
19. Lieberman JA, Pepper G, Naccache SN, Huang M-L, Jerome KR, Greninger
AL. Comparison of commercially available and laboratory developed assays
for in vitro detection of SARS-CoV-2 in clinical laboratories. J Clin Microbiol.
2020. https://doi.org/10.1128/JCM.00821-20 Published online April 29, 2020.
20. Rhoads DD, Cherian SS, Roman K, Stempak LM, Schmotzer CL, Sadri
N. Comparison of Abbott ID now, Diasorin Simplexa, and CDC FDA EUA
methods for the detection of SARS-CoV-2 from nasopharyngeal and nasal
swabs from individuals diagnosed with COVID-19. J Clin Microbiol. 2020.
doi:https://doi.org/10.1128/JCM.00760-20. Published online April 17, 2020.
21. Long Q-X, Liu B-Z, Deng H-J, et al. Antibody responses to SARS-CoV-2 in
patients with COVID-19. Nat Med 2020. doi:https://doi.org/10.1038/s41591-
020-0897-1. Published online April 29, 2020.
22. Guo L, Ren L, Yang S, et al. Profiling early Humoral response to diagnose
novel coronavirus disease (COVID-19). Clin Infect Dis 2020. doi:https://doi.
org/10.1093/cid/ciaa310. Published online March 21.
23. Sheridan C. Fast, portable tests come online to curb coronavirus pandemic.
Nat Biotechnol, 2020. doi:https://doi.org/10.1038/d41587-020-00010-2.
Published online March 23, 2020.
24. Zhang W, Du R-H, Li B, et al. Molecular and serological investigation of
2019-nCoV infected patients: implication of multiple shedding routes.
Emerg Microbes Infect. 2020;9(1):386–9. https://doi.org/10.1080/22221751.
2020.1729071.
25. Schaubel DE, Guidinger MK, Biggins SW, et al. Survival benefit-based
deceased-donor liver allocation. Am J Transplant. 2009;9(4 Pt 2):970–81.
https://doi.org/10.1111/j.1600-6143.2009.02571.x.
26. Vitale A, Volk ML, De Feo TM, et al. A method for establishing allocation equity
among patients with and without hepatocellular carcinoma on a common liver
transplant waiting list. J Hepatol. 2014;60(2):290–7. https://doi.org/10.1016/j.
jhep.2013.10.010.
27. Schlegel A, Linecker M, Kron P, et al. Risk assessment in high- and low-MELD
liver transplantation. Am J Transplant. 2017;17(4):1050–63. https://doi.
org/10.1111/ajt.14065.
28. Chui AKK, Rao ARN, Chan HLY, Hui AY. Impact of severe acute respiratory
syndrome on liver transplantation service. Transplant Proc. 2004;36(8):2302–
3. https://doi.org/10.1016/j.transproceed.2004.08.018.
29. Kumar D, Manuel O, Natori Y, et al. COVID-19: a global transplant perspective
on successfully navigating a pandemic. Am J Transplant. 2020. doi:https://
doi.org/10.1111/ajt.15876. Published online March 23, 2020.
30. Kumar D, Tellier R, Draker R, Levy G, Humar A. Severe Acute Respiratory
Syndrome (SARS) in a liver transplant recipient and guidelines for
donor SARS screening. Am J Transplant. 2003;3(8):977–81. https://doi.
org/10.1034/j. 1600-6143.2003.00197.x.
31. Kaul DR, Mehta AK, Wolfe CR, Blumberg E, Green M. Ebola virus disease:
implications for solid organ transplantation. Am J Transplant. 2015;15(1):5–6.
https://doi.org/10.1111/ajt.13093.
32. COVID-19: Advice for Clinicians - ODT Clinical - NHS Blood and Transplant.
https://www.odt.nhs.uk/deceased-donation/covid-19-advice-for-clinicians/.
Accessed 26 Mar 2020.
33. Michaels MG, La Hoz RM, Danziger-Isakov L, et al. Coronavirus disease
2019: Implications of emerging infections for transplantation. Am J Transplant
2020. doi:https://doi.org/10.1111/ajt.15832. Published online February 24,
2020.
34. Nacoti M, Ciocca A, Giupponi A, et al. At the Epicenter of the Covid-19
Pandemic and Humanitarian Crises in Italy: Changing Perspectives on
Preparation and Mitigation. NEJM Catal. 1(2). https://doi.org/10.1056/
CAT.20.0080.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
10

FEATURE
How can you reduce the risk to
your Crohn’s disease patients
of serious COVID-19 disease? 1
Prescribe
Entocort ® CR:
classified by the
BSG as lowest risk
of serious COVID-19
disease, compared
to higher-risk
prednisolone 1
Entocort ® CR: BSG-recommended control patients can count on 1–3
Entocort ® CR is indicated for the induction
of remission in adults with mild to
moderate active Crohn’s disease affecting
the ileum and/or the ascending colon. 4
ENTOCORT CR 3mg Capsules (budesonide) -
Prescribing Information
Please consult the Summary of Product Characteristics
(SmPC) for full prescribing Information
Presentation: Hard gelatin capsules for oral administration
with an opaque, light grey body and an opaque, pink cap
marked CIR 3mg in black radial print. Contains 3mg
budesonide. Indications: Induction of remission in patients
with mild to moderate Crohn’s disease affecting the ileum
and/or the ascending colon. Induction of remission in patients
with active microscopic colitis. Maintenance of remission in
patients with microscopic colitis. Dosage and
administration: Active Crohn’s disease (Adults): 9mg once
daily in the morning for up to eight weeks. Full effect achieved
in 2-4 weeks. When treatment is to be discontinued, dose
should normally be reduced in final 2-4 weeks. Active
microscopic colitis (Adults): 9mg once daily in the morning.
Maintenance of microscopic colitis (Adults): 6mg once daily in
the morning, or the lowest effective dose. Paediatric
population: Not recommended. Older people: No special
dose adjustment recommended. Swallow whole with water.
Do not chew. Contraindications: Hypersensitivity to the
active substance or any of the excipients. Warnings and
Precautions: Side effects typical of corticosteroids may
occur. Visual disturbances may occur. If a patient presents
with symptoms such as blurred vision or other visual
disturbances they should be considered for referral to an
ophthalmologist for evaluation of the possible causes.
Systemic effects may include glaucoma and when prescribed
at high doses for prolonged periods, Cushing’s syndrome,
adrenal suppression, growth retardation, decreased bone
mineral density and cataract. Caution in patients with infection,
hypertension, diabetes mellitus, osteoporosis, peptic ulcer,
glaucoma or cataracts or with a family history of diabetes or
glaucoma. Particular care in patients with existing or previous
history of severe affective disorders in them or their first
degree relatives. Caution when transferring from
glucocorticoid of high systemic effect to Entocort CR. Chicken
pox and measles may have a more serious course in patients
on oral steroids. They may also suppress the HPA axis and
reduce the stress response. Reduced liver function may
increase systemic exposure. When treatment is discontinued,
reduce dose over last 2-4 weeks. Concomitant use of CYP3A
inhibitors, such as ketoconazole and cobicistat-containing
products, is expected to increase the risk of systemic side
effects and should be avoided unless the benefits outweigh
the risks. Excessive grapefruit juice may increase systemic
exposure and should be avoided. Patients with fructose
intolerance, glucose-galactose malabsorption or sucroseisomaltase
insufficiency should not take Entocort CR. Monitor
height of children who use prolonged glucocorticoid therapy
for risk of growth suppression. Interactions: Concomitant
colestyramine may reduce Entocort CR uptake. Concomitant
oestrogen and contraceptive steroids may increase effects.
CYP3A4 inhibitors may increase systemic exposure. CYP3A4
inducers may reduce systemic exposure. May cause low
values in ACTH stimulation test. Fertility, pregnancy and
lactation: Only to be used during pregnancy when the
potential benefits to the mother outweigh the risks for the
foetus. May be used during breast feeding. Adverse
reactions: Common: Cushingoid features, hypokalaemia,
behavioural changes such as nervousness, insomnia, mood
swings and depression, palpitations, dyspepsia, skin reactions
(urticaria, exanthema), muscle cramps, menstrual disorders.
Uncommon: anxiety, tremor, psychomotor hyperactivity.
Rare: aggression, glaucoma, cataract, blurred vision,
ecchymosis. Very rare: Anaphylactic reaction, growth
retardation. Prescribers should consult the summary of
product characteristics in relation to other adverse reactions.
Marketing Authorisation Numbers, Package
Quantities and basic NHS price: PL 36633/0006. Packs of
50 capsules: £37.53. Packs of 100 capsules: £75.05. Legal
category: POM. Marketing Authorisation Holder: Tillotts
Pharma UK Ltd, The Stables, Wellingore Hall, Wellingore,
Lincoln, LN5 0HX. Date of preparation of PI: February 2020
Adverse events should be reported.
Reporting forms and information can be found at
https://yellowcard.mhra.gov.uk. Adverse events
should also be reported to Tillotts Pharma UK Ltd.
Tel: 01522 813500.
GASTROENTEROLOGY TODAY - AUTUMN 2020
References: 1. Kennedy NA et al. Gut 2020; 0: 1–7. 2. Campieri M
et al. Gut 1997; 41(2): 209–214. 3. Lamb CA et al. Gut 2019; 0: 1–106.
4. Entocort ® CR 3 mg capsules – Summary of Product Characteristics.
Date of preparation: July 2020. PU-00377.
11

FEATURE
RETHINKING HOW WE TREAT
CONSTIPATION IN THE UK
Professor Anton Emmanuel, Consultant Gastroenterologist at UCLH and the National Hospital for Neurology & Neurosurgery
In 2018 alone, the UK’s national health system (NHS) saw more
than 52,000 emergency hospital admissions for constipation –
the cost of which adds up to a staggering £71 million per year. 1
Managing such avoidable costs out of the healthcare system
is now even more of a priority given the effects of the Covid-19
pandemic and its aftermath. The NHS urgently needs nonconsultation
pathways to transform sufferers’ lives, yet also
minimise impact on precious resources.
Pyramid” which clearly plots an effective course of treatment. The pyramid
diagram shows that effective treatment of constipation should be done in
incremental stages whereby patients are moved further up the treatment
ladder until their condition comes under control. Starting from the base
layer of the pyramid, patients will first begin treatment with the most
conservative options such as adjustment of diet and fluid intake, lifestyle
alteration oral medications including stool softeners and laxatives, digital
stimulation, suppositories and biofeedback.
GASTROENTEROLOGY TODAY - AUTUMN 2020
We have to start from the question, “why is an easily manageable and
treatable condition like constipation resulting in such a high number
of unplanned emergency hospital admissions?”. The emergency
admission numbers demonstrate the urgent need to revise the current
treatment for constipation and prevent so many cases from escalating
into unwanted admissions. Unplanned hospital visits could certainly be
reduced if symptoms were identified and dealt with at the primary care
stage, but many healthcare professionals lack the right information to
effectively treat the condition. In fact, beyond standard interventions
such as laxatives and dietary changes, there is little supporting
material to guide healthcare professionals through the next stages of
treatment. Drawing on the Bowel Interest Group’s (BIG) newly published
management pathway, this article seeks to help bridge this information
gap by underlining best practices in bowel management.
One of the first barriers to effective treatment of constipation is its
perceived taboo nature. The stigma attached to constipation means that
people are suffering in silence needlessly until the condition becomes
too difficult to bear. Patients are reluctant to share symptoms with their
doctor at the early stages of the condition – with as many as one in
five stating they would be too embarrassed to talk about it at all 2 – and
therefore receive less timely treatment than they should. In parallel, the
high prevalence of these symptoms results in it being perceived by some
healthcare professionals as low risk and of minor significance, further
delaying treatment. Unfortunately, this potentially sets the stage for more
invasive interventions and unwanted hospital admissions in the long run.
With bowel behaviour serving as an important indicator of our health,
it is crucial that we break down this wall and promote more open
conversations about bowel health. Greater awareness about constipation,
as well as correct advice and treatment, will help to make people feel
more comfortable talking to their GP. Without intervention, people with
bowel disorders can suffer from reduced quality of life including feelings
of embarrassment, anxiety and depression – as well as a number of
unwanted side-effects such as urinary tract infections (UTIs). Failure to
deal with symptoms promptly can lead to more complex problems such
as haemorrhoids, anal fissures or rectal prolapse, so it is important to
diagnose and treat the condition as early as possible.
The next step is ensuring that healthcare professionals themselves are
sufficiently informed about treatment options for constipation. In support,
the Bowel Interest Group has developed a ‘Bowel Dysfunction Treatment
If these standard interventions are not effective within the prescribed
three-month period, patients would typically then progress onto the next
stage of treatment: minimally invasive treatment options such as transanal
irrigation (TAI). It is important that the prescribed length of treatment is
consistently adhered to at every level and that patients are moved up the
pyramid once the given timeframe has elapsed. This ensures that patients
suffering from constipation can reach the appropriate therapy level and
resume their normal lives as quickly as possible. The upper layers of the
treatment pyramid are comprised of more invasive treatment options such
as nerve stimulation implants and surgical colonic irrigation. Finally, the
last recourse if these are ineffective, is the creation of a permanent stoma
– which constitutes the peak of the pyramid.
Another important consideration for GPs and Clinical Commissioning
Groups is the cost associated with each therapy. BIG’s pyramid diagram
provides this valuable information, sub-categorized into the one-off cost,
the annual cost and the 7-year cost for each treatment. For instance,
while the cost of standard starting treatment should amount to £2,539,
this figure can reach up to £32,298 over seven years if practitioners do not
progress their patients up the pyramid towards more effective treatment
within the recommended timeframe. 3 Respecting the designated
timeframe for each treatment echelon therefore makes sense from both a
patient-outcome perspective as well as from a financial outlook.
Bowel management in the UK is in need of urgent reform, despite
pockets of excellence scattered across the country. Today, constipation
is often perceived as low priority despite having a hugely detrimental
impact on the patients it affects, as well as the financial burden that its
ineffective treatment imposes on the healthcare system. Having the right
pathways in place at the primary level is crucial to ensuring patients
do not require unplanned emergency interventions within already
overstretched facilities. The Covid-19 experience has served to highlight
even further the requirement for non-consultation pathways to transform
sufferers’ lives, yet also minimise impact on precious resources.
Securing these outcomes will take a nationwide effort to rebuild our
understanding of the management of constipation.
Please find the Bowel Interest Group’s full report - Dealing with Chronic
Constipation: Information for General Practitioners:
https://bowelinterestgroup.co.uk/resources/dealing-with-chronicconstipation-information-for-general-practitioners/
12
1
Bowel Interest Group, Cost of Constipation Report, Second edition, 2019
2
Ibid
3
Bowel Interest Group, Dealing with Chronic Constipation: Information for General Practitioners, 2020

The only licensed treatment for the
ADVERTORIAL FEATURE
reduction in recurrence of overt
hepatic encephalopathy (OHE) 1
At home they
are still at risk;
…TARGAXAN ®
rifaximin-α
reduces the risk
of recurrence
of overt hepatic
encephalopathy. 2
Long-term secondary prophylaxis in hepatic
encephalopathy (HE) 3
UK&IE Prescribing Information: Targaxan 550mg (rifaximin-α)
REFER TO FULL SUMMARY OF PRODUCT CHARACTERISTICS (SmPC)
BEFORE PRESCRIBING
Presentation: Film-coated tablet containing rifaximin 550 mg.
Uses: Targaxan is indicated for the reduction in recurrence of episodes
of overt hepatic encephalopathy in patients ≥ 18 years of age.
Dosage and administration: Adults 18 years of age and over: 550 mg
twice daily, with a glass of water, with or without food for up to
6 months. Treatment beyond 6 months should be based on risk benefit
balance including those associated with the progression of the patients
hepatic dysfunction. No dosage changes are necessary in the elderly or
those with hepatic insufficiency. Use with caution in patients with renal
impairment.
Contraindications: Contraindicated in hypersensitivity to rifaximin,
rifamycin-derivatives or to any of the excipients and in cases of intestinal
obstruction.
Warnings and precautions for use: The potential association of
rifaximin treatment with Clostridium difficile associated diarrhoea and
pseudomembranous colitis cannot be ruled out. The administration
of rifaximin with other rifamycins is not recommended. Rifaximin
may cause a reddish discolouration of the urine. Use with caution
in patients with severe (Child-Pugh C) hepatic impairment and in
patients with MELD (Model for End-Stage Liver Disease) score > 25.
In hepatic impaired patients, rifaximin may decrease the exposure
of concomitantly administered CYP3A4 substrates (e.g. warfarin,
antiepileptics, antiarrhythmics, oral contraceptives). Both decreases and
increases in international normalized ratio (in some cases with bleeding
events) have been reported in patients maintained on warfarin and
prescribed rifaximin. If co-administration is necessary, the international
normalized ratio should be carefully monitored with the addition or
withdrawal of treatment with rifaximin. Adjustments in the dose of
oral anticoagulants may be necessary to maintain the desired level of
anticoagulation. Ciclosporin may increase the rifaximin C max
Pregnancy and lactation: Rifaximin is not recommended during
pregnancy. The benefits of rifaximin treatment should be assessed
against the need to continue breastfeeding.
Side effects: Common effects reported in clinical trials are dizziness,
headache, depression, dyspnoea, upper abdominal pain, abdominal
distension, diarrhoea, nausea, vomiting, ascites, rashes, pruritus,
muscle spasms, arthralgia and peripheral oedema. Other effects that
have been reported include: Clostridial infections, urinary tract
infections, candidiasis, pneumonia cellulitis, upper respiratory tract
infection and rhinitis. Blood disorders (e.g. anaemia,
thrombocytopenia). Anaphylactic reactions, angioedemas,
hypersensitivity. Anorexia, hyperkalaemia and dehydration. Confusion,
sleep disorders, balance disorders, convulsions, hypoesthesia,
memory impairment and attention disorders. Hypotension,
hypertension and fainting. Hot flushes. Breathing difficulty, pleural
effusion, COPD. Gastrointestinal disorders and skin reactions. Liver
function test abnormalities. Dysuria, pollakiuria and proteinuria.
Oedema. Pyrexia. INR abnormalities. Prescribers should consult the
SmPC in relation to all adverse reactions.
UNITED KINGDOM
Legal category: POM
Cost: Basic NHS price £259.23 for 56 tablets
Marketing Authorisation holder: Norgine Pharmaceuticals Limited,
Norgine House, Widewater Place, Moorhall Road, Harefield, Uxbridge,
UB9 6NS, UK
Marketing Authorisation number: PL 20011/0020
IRELAND
Legal category: Prescription only
Cost: €262.41 for 56 tablets
Marketing Authorisation holder: Norgine B.V. Antonio Vivaldistraat 150,
1083 HP, Amsterdam, Netherlands
Marketing Authorisation number: PA 1336/009/001
For further information contact: Norgine Pharmaceuticals Limited,
Norgine House, Moorhall Road, Harefield, Middlesex UB9 6NS
Telephone: 01895 826 606 E-mail: Medinfo@norgine.com
Ref: UK/XIF5/0519/0509
Date of preparation: May 2019
United Kingdom
Adverse events should be reported. Reporting forms and
information can be found at www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to Medical
Information at Norgine Pharmaceuticals Ltd on:
Tel. +44 (0)1895 826 606 Email Medinfo@norgine.com
Ireland
Healthcare professionals are asked to report any suspected
adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace,
IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517.
Website: www.hpra.ie; E-mail: medsafety@hpra.ie.
Adverse events should also be reported to Medical Information
at Norgine Pharmaceuticals Ltd on: Tel. +44 (0)1895 826 606
Email Medinfo@norgine.com
References:
1. National Institute for Health and Care Excellence. Rifaximin for
preventing episodes of overt hepatic encephalopathy: appraisal
guidance TA337 for rifaximin. Available from: http://www.nice.org.
uk/guidance/ta337
2. TARGAXAN ® 550 Summary of Product Characteristics. Available
for the UK from: https://www.medicines.org.uk/emc Available for
Ireland from: www.medicines.ie
3. Mullen KD, et al. Clin Gastroenterol Hepatol 2014;12(8):1390-97.
Product under licence from Alfasigma S.p.A. TARGAXAN is a
registered trademark of the Alfasigma group of companies, licensed
to the Norgine group of companies. NORGINE and the sail logo are
registered trademarks of the Norgine group of companies.
UK/XIF5/0919/0549
Date of preparation: October 2019.
GASTROENTEROLOGY TODAY - AUTUMN 2020
13

GASTROENTEROLOGY TODAY - AUTUMN 2020
NHS trusts with:
2WW Urgent referrals
Routine referrals
ADVERTORIAL FEATURE
Surveillance cases
Bowel cancer screening services
ENDOSCOPY ALTERNATIVES IN A TIME OF COVID:
NHS Facility NHS Staff NHS
INNOVATIVE THINKING AND DIFFERENT WAYS OF WORKING
processes
TO CLEAR NHS TRUSTS WAITING LISTS
Enhanced sedation (Propofol) lists
Additionally, we can support Direct Access
and Rapid Access endoscopy referrals by
working with the local clinical leads to agree
strong governance for the management of
these patients.
This quarter we explore the potential for Transnasal endoscopy as a
new technological alternative which may assist Trusts in managing
the significant spike in diagnostics demand arising from COVID 19.
Transnasal endoscopy, or TNE, is an upper GI endoscopy method which
is performed by the nasal route (rather than the oral route) using a thin
Criteria & Quality
endoscope less than 6 mm in diameter. This technique has been shown
to improve patient tolerance and is more convenient.
We select Endoscopists with an endoscopy
orientated career path and performance
measures above the national average. JAG
audit data is constantly monitored to ensure
has prevented successful internal review.
ongoing quality. Furthermore, we have a
Sedation is not required during Transnasal endoscopy and therefore
clinical governance department that is crucial
to maintaining quality and safety but also
provides support to both Endoscopists and
ensuring diagnostics continue while, importantly, being separated
the from units COVID within red zones. which Recovery we times work. are short and the patient is
Unsedated conventional oral gastroscopy (c-OGD) commonly causes
gagging, retching and nausea which are avoided with TNE due to limited
stimulation of the tongue and soft palate, thus saving treatment time and
occasional repeat patient visits where physical rejection of the camera
nursing staff will not be required for monitoring patient vital signs, offering
an immediate cost-saving. The procedure can furthermore be carried
out in an outpatient setting with a smaller estates footprint, importantly
able to leave the room and hospital immediately once the procedure
is completed and without the need for further monitoring or recovery
We provide tailored solutions to manage
capacity from straight forward supply of staff
to a team based managed solution to a full
patient pathway including pathology review.
facilities (Gorelick et al. 2001). There are a number of cost analyses
clearly demonstrating the cost savings for TNE (Wellenstein et al. 2019;
Anon n.d.; Atar and Kadayifci 2014), and these come from a combination
of decreasing the cost and total duration of endoscopic procedures,
increased capacity and reduced staff requirements and all while allowing
deployment in safe, manageable outpatient settings.
Accuracy of Diagnosis
Our commitment to improving the
NHS experience
conventional endoscopes, thus maintaining the diagnostic accuracy.
Like Current the data NHS suggests Trusts that TNE we has work better with, patient tolerance patient when
care is at the centre of everything we do. By
using any spare weekend capacity within a
Trust, the 18 Week Support insourcing teams
Training & Deployment
are able to see a high volume of patients
in a short space of time, in the familiar
surrounding of the NHS Trust.
To date, data suggests that there is preservation of the image quality of
compared to unsedated endoscopy (Garcia et al. 2003; Parker et al. 2016;
Schuldt et al. 2019). Nasal pain is the most significant symptom associated
with endoscopic procedures but can be reduced with nasal pre-treatment.
Transnasal endoscopes are very similar to standard or slim endoscopes
except for their outer diameter, which is usually less than 6 mm, and a
smaller working channel, of only 2 mm in diameter. The disadvantage
of this smaller calibre working channel is that only specialist paediatric
biopsy forceps can be used to take tissue samples. There is the risk that
An ethical company
We’re an ethical and transparent company
that’s financially accountable and financially
responsible.
rooms is not required.
We’re committed to the NHS
14and the delivery of high-quality care, and to
helping Trusts reduce RTT waiting times.
histological analysis may be impaired with smaller tissue samples.
Implementation of TNE requires procurement of the endoscopes and if
necessary a dedicated processor. The fact that these procedures can
be carried out in outpatient settings means that refurbishing hospital
Clinical team
There is no formal training program for TNE, but all endoscopists
undertaking Trans-nasal endoscopy procedures must have JAG
certification for diagnostic UGI endoscopy (oral route). However, there
is a requirement to understand the nasal anatomy and how to deal with
complications. There are also subtle differences to the techniques required
to negotiate some aspects of the anatomy, particularly large hiatus hernias
Happy patient
and passage through to D2. There are training courses available, which
JAG strongly recommends clinicians attend. It is recommended that
ENT surgeons should be involved at local service level to understand
the anatomical approach and managing complications, and to provide
mentoring. It is advised that a minimum of 20 full procedures are observed
Who we’re looking for
and competencies met before independent practice.
We are interested in meeting with Consultant
Summary
Gastroenterologists, senior nurses and clinical
nurse specialists throughout the UK.
Transnasal endoscopy offers Trusts considerable advantages and
flexibility during this time of COVID. TNE can be safely and easily
deployed, including in outpatient settings which makes it easy to keep
Our remuneration package is second to
none and is per session rather than per case
which allows our teams to work in a safe and
Bibliography
calm environment’
diagnostic patients separate from COVID red zones; accurate diagnostic
results can be delivered with smaller teams and with reduced impact on
the patient; and special TNE training and deployment needs are limited.
Anon Cost Savings of Transnasal Endoscopy Versus Standard Endosco...: Official
journal of the American College of Gastroenterology | ACG [Online]. Available at:
https://journals.lww.com/ajg/Fulltext/2008/09001/Cost_Savings_of_Transnasal_
Endoscopy_Versus.1037.aspx About you [Accessed: 24 August 2020a].
Atar, M. and Kadayifci, A. 2014. Transnasal endoscopy: Technical considerations,
advantages and limitations. World journal of gastrointestinal endoscopy 6(2), pp. 41–48.
If you have an excellent NHS record and
Garcia, R.T., Cello, J.P., Nguyen, M.H., et al. 2003. Unsedated ultrathin EGD is well
accepted when compared with conventional sedated EGD: a multicenter randomized
trial. want Gastroenterology to help 125(6), clear pp. 1606–1612. NHS waiting list
backlogs, reduce RTT waiting times and
provide high-quality patient care, get in
touch by calling on 020 3966 9081 or email
Gorelick, A.B., Inadomi, J.M. and Barnett, J.L. 2001. Unsedated small-caliber
esophagogastroduodenoscopy (EGD): less expensive and less time-consuming than
conventional EGD. Journal of Clinical Gastroenterology 33(3), pp. 210–214.
Parker, C., Alexandridis, E., Plevris, J., O’Hara, J. and Panter, S. 2016. Transnasal
endoscopy: no gagging no panic! Frontline gastroenterology 7(4), pp. 246–256.
Schuldt, A.-L., Kirsten, H., Tuennemann, J., et al. 2019. Necessity of transnasal
gastroscopy recruitment@18weeksupport.com
in routine diagnostics: a patient-centred requirement analysis. BMJ open
gastroenterology 6(1), p. e000264.
Wellenstein, D.J., Honings, J., Schutte, H.W., et al. 2019. Cost analysis of office-based transnasal
esophagoscopy. European Archives of Oto-Rhino-Laryngology 276(5), pp. 1457–1463.
18 Week Support
www.18weeksupport.com
Dr Matthew Banks Banks
Clinical Lead for Gastroenterology
18 Week Support
London 3rd Floor, 19-21 Great Tower Street, London EC3R 5AR
Birmingham Unit 25, Lichfield Business Village, The Friary WS13 6QG
GASTROENTEROLOGY TODAY - SPRING 2019

UEG Week – World Class Scientific Research
Meet. Exchange. Evolve
NEWS
UEG Week goes virtual: October 11–13, 2020
ueg.eu/week
GASTROENTEROLOGY TODAY - AUTUMN 2020
15

NEWS
Simpler diagnostic process
for adults with suspected
coeliac disease could
reduce NHS waiting lists and
improve patient health faster
The British Society of Gastroenterology
(BSG) has issued interim guidance,
pending the publication of its new Coeliac
Guidelines in 2021, so that some adults
with suspected coeliac disease can now
be diagnosed based on blood test results
alone, cutting out the long wait for an
endoscopy with biopsy.
Diagnosis of coeliac disease in adults is usually
a two-step process, a blood test to look for
antibodies followed by an endoscopy with
biopsy to look for damage to the intestine.
Early in the coronavirus pandemic, the
BSG recommended that non-emergency
endoscopies should be paused to protect
NHS staff and patients from coronavirus
transmission. This meant that many people with
suspected coeliac disease have been unable to
have an endoscopy as part of their diagnosis.
Hilary Croft, Chief Executive of Coeliac UK
said: “Coeliac UK has previously called for
the national guidelines to review the evidence
for adult no-biopsy diagnosis and so fully
supports the BSG’s new position. This will
enable a greater number of people to gain
a faster diagnosis, without the need to wait
for an endoscopy at the hospital. Getting an
accurate diagnosis of coeliac disease means
keeping gluten in the diet throughout the
testing process - a difficult feat when waiting
lists are long and people feel unwell.”
The interim guidance published due to the
impact of Covid-19 on endoscopy waiting
lists, suggests that a no-biopsy diagnosis can
be used for adults under 55 years of age with
symptoms of coeliac disease who:
• Don’t need an endoscopy to rule out other
conditions
• Have antibody levels (IgA tissue
transglutaminase) at least 10 times the
upper limit of normal
• Have a second positive antibody blood test
(endomysial antibodies (EMA) or tissue
transglutaminase if EMA isn’t available)
A GP can request the initial antibody blood test
but the decision about whether an endoscopy
and biopsy is needed, and the final diagnosis
of coeliac disease, should be made by a
gastroenterologist. The impact of this new
diagnosis pathway will be closely monitored, and
data is being collected to assess the impact of
this new approach for adults. For children, since
2013, guidelines have recommend a no-biopsy
diagnosis for some children.
“These guidelines are good news for those
who meet the criteria for a no-biopsy diagnosis
who will be able to start to feel better sooner
on a gluten free diet, the only treatment for
coeliac disease. However, those that do not
meet the criteria for no-biopsy diagnosis are
likely to face long waiting times as endoscopy
services begin a phased return. Access to
blood tests may still be limited at the moment,
so we encourage people to speak with their
GP for more information about diagnosis
of coeliac disease if they are experiencing
symptoms,” continued Ms Croft.
Coeliac disease is not an allergy or an
intolerance but an autoimmune disease where
the body’s immune system damages the lining
of the small bowel when gluten, a protein
(found in wheat, barley and rye) is eaten.
There is no cure and no medication; the only
treatment is a strict gluten free diet for life. 1
in 100 people in the UK has coeliac disease
but only 30% of those with the condition have
been diagnosed. There are an estimated
half a million people in the UK who have the
condition yet don’t know it.
There is a wide range of symptoms associated
with coeliac disease. Some symptoms may be
confused with irritable bowel syndrome (IBS)
or wheat intolerance, while others may be put
down to stress or getting older.
To make it easier to understand if symptoms
are possibly due to coeliac disease and
discuss further testing with your GP, Coeliac
UK has developed a self assessment test
to make it easier to take that first step to
diagnosis.
Go to www.isitcoeliacdisease.org.uk to take
the online assessment.
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GASTROENTEROLOGY TODAY - AUTUMN 2020
Gastroenterology Today welcomes the submission of
clinical papers and case reports or news that
you feel will be of interest to your colleagues.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
16
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com

BIOHIT ULTRA-FAST UFT300
HELICOBACTER PYLORI QUICK TEST
NEWS
A five-minute urease test
for gastric biopsies
As lockdown begins to ease and your endoscopy
services restart, our UFT300 Helicobacter pylori Quick
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important than ever.
BIOHIT HealthCare’s quick and simple to use ultra-fast
UFT300 Helicobacter pylori Quick Test is the market-leading
kit for the diagnosis of H. pylori infection in both NHS and
private endoscopy departments. It offers accuracy and a
clinical performance comparable to gold standard methods, 1 Key advantages of the UFT300 Helicobacter pylori Quick Test:
allowing a reliable diagnosis to be made in just five minutes.
This rapid kit provides the opportunity to test, report and • Results in five minutes
treat the patient in a single appointment at the point of
• Ready to use
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• High accuracy minimises false positives and negatives
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H. pylori infection is a significant and independent risk factor • Sensitivity 94.3 %, specificity 100 % (compared to histology
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Helicobacter pylori Quick Test is a rapid urease test that has
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change determines the presence of urease – produced by H. endoscopy staff and covers a range of topics, including H.
pylori – within the sample. With extremely high accuracy and pylori infection, urease tests, and the use and interpretation
every result available within five minutes, this ready-to-use of the UFT300 Helicobacter pylori Quick Test. A certificate is
test is the preferred choice for endoscopists.
awarded on completion of the course.
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1
Vaira D et al. Accuracy of a new ultrafast rapid urease test to diagnose Helicobacter pylori infection in 1,000 consecutive dyspeptic patients. Aliment Pharmacol Ther 2010; 31, 331-338.
GASTROENTEROLOGY TODAY - AUTUMN 2020
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17

NEWS
Cost of constipation still
rising in most English
regions, reveals new report
from the independent Bowel
Interest Group
(Letchworth, August 2020)
Newly released data from the Bowel
Interest Group – published in the 2020
edition of its Cost of Constipation report
– has revealed that the cost of avoidable
emergency admissions to hospital because
of constipation is rising year-on-year in most
regions of England. Just six regions have
seen a drop in the cost and/or number of
admissions for constipation compared to two
years prior. This comes at a time when the
NHS is already under stress and is dealing
with the backlog of patients with chronic
conditions who have had their treatments
delayed because of the coronavirus
pandemic.
The Cost of Constipation report reveals the
impact that constipation has on patients’
quality of life, the significant cost of
constipation to the NHS as well as how this
varies by region. Nationally, the cost per
100,000 population of avoidable constipationrelated
emergency admissions was over
£158,000 in 2018/19. This represents a
15% rise compared with 2016/17 (around
£137,000). Regional variations were
marked, ranging from around £106,000 per
100,000 in Bristol, North Somerset & South
Gloucestershire, through to £244,000 per
100,000 in Humber, Coast & Vale. This level
of variation underlines the importance of
establishing and implementing best practice
bowel management across the country.
At a national level, the report shows that
poor bowel health and chronic constipation,
which are debilitating for hundreds and
thousands of people in the UK, cost the NHS
£81 million per year in admissions to A&E for
constipation. This cost is likely to be much
higher when GP visits, home visits and over
the counter laxatives are taken into account.
Other key figures include:
• £168 million was spent treating
constipation in 2018/19. This includes
avoidable admissions to A&E for
constipation (£81 million) and prescription
laxative costs (£87 million).
• The cost of treating constipation in 2018/19
is equivalent to funding 7304 newlyqualified
nurses for a year.
• Only 6 out of 42 regions (STPs or ICSs
as applicable) in England have seen a
decrease in the number and/or cost of
avoidable emergency admissions for
constipation.
Some leading NHS Trusts in England have
established formal Bowel Management
Pathways and these pioneering initiatives
are starting to offer empirical proof of their
value, both in transforming patients’ lives
and reducing the cost burden on the NHS.
The Bowel Interest Group publicises clinical
best practice on its website, and further
information from the National Institute for
Health and Care Excellence also offers further
guidance for practitioners[1].
Dr Ben Disney, Consultant Gastroenterologist
at Coventry and Warwickshire University
Hospitals Trust and Bowel Interest Group
board member, comments, “This latest
output from the Bowel Interest Group should
make everyone sit up and take notice. Not
only does chronic constipation ruin people’s
lives, it also is causing the NHS unnecessary
costs, largely because dedicated Bowel
Management Pathways are not yet standard
best practice. Pioneering work in this area has
clearly shown a strong return on investment
from such pathways, both in terms of patient
outcomes and cost reduction. At a time when
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GASTROENTEROLOGY TODAY - AUTUMN 2020
If you have submitted a poster to previous BSG or
ENDOLIVE events and would like it published in
Gastroenterology Today please forward a PDF of your
poster to the email address listed below.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com
18

NEWS
our NHS is under such pressure, failing to
establish these pathways would seem poor
practice. Modern healthcare is not simply
about treating the escalating rise in chronic
conditions, but also taking pre-emptive action
to create more ‘well societies’. Effective bowel
management is just one of the initiatives
that help foster healthier populations that
consume less healthcare.”
The Bowel Interest Group is an independent
multidisciplinary organisation dedicated to
improving bowel care for patients.
You can download the full report free of
charge by visiting:
https://bowelinterestgroup.co.uk/
resources/cost-of-constipationreport-2020/
New information pack
supports GPs in best practice
treatment of constipation
(Letchworth, February 2020) Independent
clinical and patient organisation, The Bowel
Interest Group (BIG), has published a new
information pack for General Practices on
managing acute constipation through key
therapeutic stages, ensuring that patients
are not left for long periods with treatments
that are not working.
Constipation (and its frequent companion
symptom – faecal incontinence) ruins lives.
Yet the condition is still under-managed in
the National Health Service, despite some
fundamentally important foundation work 1 .
In particular, survey work with GPs,
conducted by BIG in 2019, has revealed
that supporting materials for healthcare
professionals at the primary level on
constipation management are scant, and
are one of the key resources sought by
GPs. Most of these patients are treated
empirically with laxatives, with little subtlety
of which agent suits the individual patient’s
symptoms. Respondents to the survey said
they would welcome useful resources on
the issue. This new document is one step in
redressing that balance.
Poor bowel health and chronic constipation
is debilitating for hundreds and thousands of
people in the UK. In 2017/18, it cost the NHS
£162 million in constipation treatment, of
which £71 million was caused by unplanned,
avoidable emergency admissions, and
£91 million by spending on prescription
laxatives i .
The newly published information pack
- Dealing with Acute Constipation,
Information for General Practitioners -
summarises key research on constipation
and treatment options and combines them
into a simple diagram to help provide a
best practice pathway for general practice
in its recognition, treatment and point of
escalation of the available therapies for
acute constipation.
Professor Anton Emmanuel, Consultant
Gastroenterologist at UCLH and the National
Hospital for Neurology & Neurosurgery,
lead the compilation of the new information
pack. He notes, “Many Trusts have now
created, or are developing, dedicated bowel
management pathways based on NICE
guidance, and are already experiencing the
resulting improved patient outcomes. BIG
have created a management pathway based
on the NICE Clinical Knowledge Summary.
This document is aimed at all clinicians,
specialist care professionals, general
practitioners and commissioners to help
understand the rationale and positioning
of this therapy that can have a profoundly
positive effect on people’s health, quality of
life, dignity and requirement for healthcare.”
i
Bowel Independence Group, The Cost of
Constipation Report 2019
WHY NOT WRITE FOR US?
Gastroenterology Today welcomes the submission of
clinical papers and case reports or news that
you feel will be of interest to your colleagues.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com
GASTROENTEROLOGY TODAY - AUTUMN 2020
19

NEWS
UEG Week Goes Virtual!
UEG Week Virtual 2020, October 11-13, 2020
With over 13,000 attendees from more than
120 countries in 2019, UEG Week is one of
the world’s largest and most prestigious
digestive health meetings. Given the
present circumstances facing the world
today, the decision has been made to hold
UEG Week virtually this October, ensuring
the safety of the digestive health community
while still allowing advanced scientific
exchange.
3-day schedule, with state-of-the-art science
continuing to form an essential part of the
meeting and abstract review process. As well
as accessing brand new research via latebreaking
abstracts, delegates will also be able
to explore the status and impact of COVID-19 on
gastrointestinal and hepatology-related fields.
The live programme will run from 08:30-
20:30 CET each day of the congress. For
those accessing the meeting from different
time zones, the UEG Week platform will be
accessible 24 hours a day to browse ondemand
content. The virtual platform will also
remain accessible after the live event, until the
end of December 2020, and all recordings
will then be permanently available in the UEG
Library.
The majority of the programme features live
interaction between moderators, speakers
and the audience, providing the opportunity
for debate and knowledge exchange. Each
day, there will also be a live broadcast from the
UEG Week Virtual 2020 TV Studio. Featuring
the most exciting and newsworthy topics
from the congress, participants can tune into
the studio and ask real-time questions via a
specialised Q&A virtual tool. This studio will
also host the hugely popular ‘Mistakes in…’
sessions, featuring a range of topics including
pancreatitis, alcohol-related liver disease,
small bowel bleeding and chronic diarrhoea.
Practical-minded delegates can benefit
from the live streamed endoscopy and live
ultrasonography demonstrations, providing
a unique opportunity for attendees to watch
and learn techniques from some of the world’s
leading specialists.
As for postgraduate teaching, UEG is pleased
to offer a ‘best of’ Postgraduate Teaching
programme from previous congresses. Taking
place virtually between November 27-28 2020,
this two-day event will provide attendees with
the most important knowledge in digestive
health from renowned experts, in a highly
interactive format. Registration for this event
opens on August 10, 2020.
“We remain dedicated to organising a highquality
meeting and our programme will still
deliver the latest and greatest in science”,
adds Axel Dignass. “Now more accessible
to our community throughout the world, we
are thrilled to bring delegates this new virtual
platform and I am thoroughly looking forward
to welcoming new and returning delegates to
UEG Week Virtual 2020.”
Visit ueg.eu/week
GASTROENTEROLOGY TODAY - AUTUMN 2020
Axel Dignass, UEG President, explains,
“COVID-19 is the greatest global health
challenge we have seen in decades. For UEG,
the health and safety of our community is a
top priority. We now lead by example in taking
this important decision and invite attendees
to meet, exchange and evolve virtually for the
best gastroenterology congress in the world.”
As always, the UEG Scientific Committee has
pieced together the congress programme,
featuring a variety of exciting topics covering
all aspects of digestive health. A range of
session types will exist to showcase the best
science across these areas, ensuring the
delivery of a first-class and multidisciplinary
programme to all attendees, no matter where
they will be joining the congress from.
The programme has been adapted to a new
20

NEWS
Bowel Interest Group
launches updated Interactive
Treatment Pathway for
chronic constipation patients
(Letchworth, 18 June 2020)
Research has shown that chronic
constipation is costing the NHS £71 million/
year in avoidable, unplanned emergency
hospital admissions. Bowel complaints carry
an enormous stigma, with one on five too
embarrassed to talk to their GP – the same
level of embarrassment associated with
erectile dysfunction. Even more importantly,
there is a long-term impact on wellbeing
and quality of life. Chronic constipation can
cause debilitating physical and psychological
distress, especially as it can cause other
issues, such as chronic pain and urinary
tract infections (UTIs). Yet constipation is
a treatable and manageable condition,
so earlier and improved treatment would
alleviate an unnecessary burden on the NHS.
Data shows that lack of information and
dedicated bowel management pathways is
impeding the early escalation of chronic
constipation towards effective treatment
and improved patient outcomes. To assist
healthcare professionals in both primary
and acute sectors, the Bowel Interest
Group has launched an updated edition
of its Interactive Treatment Pathway for
chronic constipation.
The pathway constitutes an easy reference
guide for treating adults with chronic
constipation. The interactive treatment
pathway starts at the initial consultation
through to third line therapies and when
to refer to secondary care. It has been
specifically developed to improve care
and reduce costs associated with chronic
constipation in the community.
Recognising that this issue is a particularly
significant problem in primary care, the
guidance is structured pragmatically to
allow quick and safe decision making. The
first appointment may just cover history and
examination. The pathway would then assist
by standardising the lifestyle measures
which have evidence to support them. The
pathway has been developed from the
NICE CKS on constipation and is interactive
to allow healthcare professionals to click
through to the relevant section during
patient consultation.
Professor Anton Emmanuel, Consultant
Gastroenterologist at UCLH and the
National Hospital for Neurology &
Neurosurgery, who led the development of
the Interactive Pathway, comments:
“Despite the availability of specific NICE
guidance on bowel management, and the
pioneering work of some NHS Trusts on
the issue, widespread effective treatment
of chronic constipation still has some way
to go. It is therefore important that BIG
have published this Interactive Treatment
Pathway which simply and safely leads
practitioners through the clinical decision
making process, based on the NICE
guidance. Better treatment of constipation
reduces the burden on the NHS while also
having a profoundly positive effect on
people’s health, quality of life, dignity and
requirement for healthcare. This document
is a support tool aimed at all clinicians,
specialist care professionals, general
practitioners and commissioners and can
be used in tandem with the other important
information on the subject published by the
Bowel Interest Group.”
WHY NOT WRITE FOR US?
Gastroenterology Today welcomes the submission of
clinical papers and case reports or news that
you feel will be of interest to your colleagues.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com
GASTROENTEROLOGY TODAY - AUTUMN 2020
21

COMPANY NEWS
BIOHIT SUPPLIES COVID-19
DETECTION KITS IN THE UK
BIOHIT Healthcare Ltd is now distributing test kits for the
diagnosis of both current and past COVID-19 infections to
help in the fight against coronavirus in the UK. The new
product line includes the MutaPLEX ® Coronavirus kit from
Immundiagnostik AG (IDK) – a real-time RT-PCR assay to
screen for infected individuals – and Epitope Diagnostics Inc’s
(EDI’s) immunodiagnostic tests for IgM and IgG COVID-19
antibodies, to detect past infections.
The IDK MutaPLEX coronavirus screening assay allows the detection of
SARS-CoV-2 viral RNA in a variety of biological specimens, especially nasal/
throat swabs. This real time RT-PCR kit contains all the reagents, primers
and dual-labelled probes required for the amplification and simultaneous
differentiation of RNA from SARS-CoV-2 and other betacoronaviruses, as
well as house-keeping genes designed to prevent false negative results
due to insufficient sample collection or transport problems.
EDI’s Novel Coronavirus COVID-19 ELISA kits provide qualitative detection
of antibodies in patient serum, indicating a past COVID-19 infection. The
IgM assay provides the earliest immunodiagnostic indication of an infection,
while the IgG test can be used to aid detection and provide an indication
of long-term immunological response, making it particularly useful in cases
where clustering is suspected or differential diagnosis is required.
These tests extend and complement BIOHIT’s repertoire of diagnostic kits
for gastroenterology, aiding the evaluation of patients with both GI and
upper respiratory complaints, as COVID-19 may include stomach and
bowel symptoms in some cases. Inflammatory bowel disease patients
being treated with immunosuppressive agents should also be considered
at high risk for COVID-19, making differential diagnosis essential.
Graham Johnson, Managing Director of BIOHIT Healthcare Ltd,
commented: “Access to diagnostic testing is vital to coordinate an
effective response to this global pandemic. By distributing these kits,
we hope to streamline and simplify the UK supply chain, allowing more
people to be tested sooner. This is just one piece of the puzzle, but it is
important that we all do our small part in protecting both individuals and
the NHS and, ultimately, saving lives.”
About BIOHIT Healthcare Ltd
BIOHIT Healthcare Ltd (www.biohithealthcare.co.uk) is part of
the Finnish public company, BIOHIT OYJ, which specialises in the
development, manufacture and marketing of products and analysis
systems for the early diagnosis and prevention of gastrointestinal
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monitoring of gastrointestinal diseases efficient and cost effective.
Non-invasive diagnostics are at the core of BIOHIT’s offering, making
it the provider of choice for leading gastroenterologists and laboratory
scientists worldwide.
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GASTROENTEROLOGY TODAY - AUTUMN 2020
22
If you have submitted a poster to previous BSG or
ENDOLIVE events and would like it published in
Gastroenterology Today please forward a PDF of your
poster to the email address listed below.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com

A Huge Thank You to The NHS from the
Gastroenterology Today Junior Team
Carys - Age 6
Zoe - Age 7
Luke - Age 10
Joseph - Age 5
Thank You
Thank You
Thank You
Aoife - Age 4
Charlotte - Age 3
Rory - Age 2

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